University of Ghana http://ugspace.ug.edu.gh SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON PLANNED BEHAVIOUR OF MOTHER IN-LAWS ABOUT TRADITIONAL NEWBORN CARE PRACTICES IN THE NORTH GONJA DISTRICT BY ABDUL-MUMIN AMANKWA (10804032) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PHILOSOPHY IN NURSING DEGREE JULY, 2021 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES DECLARATION I, Amankwa Abdul-Mumin, do honestly declare that this thesis is my own private work done under the supervision of both my principal supervisor and co-research supervisor, except where references have been properly acknowledged. I also declare that, this thesis in its whole or portions has not been submitted for the award of a baccalaureate in any university. Signatories 16/08/2021 AMANKWA ABDUL-MUMIN Date (Candidate) 18/08/2021 DR. FLORENCE NAAB Date (Principal Supervisor) 17/08/2021 MISS. ERNESTINA ASIEDUA Date (Co-research supervisor) i University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES DEDICATION I dedicate this research work to my family and friends especially my son, Amankwa Abdul-Barri and to my late father, Mr. Amankwa Mallam Yahaya. ii University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES ACKNOWLEDGEMENT Alhamdullilah!! Alhamdullilah!! Alhamdullilah!! I am most grateful to the Almighty Allah for granting me good health, wisdom and strength to conduct this study from the beginning to a successful end. To my indefatigable supervisors, Dr. Florence Naab and Miss. Enerstina Aseidua I owe you gratitude for your loving support, patience and guidance. Indeed, you are my pathfinder and I am most grateful to you both, Allah bless you. With due diligence, I acknowledge the tremendous support of all faculty members of the School of Nursing and Midwifery (SoNM), University of Ghana, Legon from the day I reported as an MPhil. Student. Also, I thank the Director for Health Services, North Gonja District and all the staffs at the Daboya Poly-clinic for their immense support in this study. Again, I thank all my family and friends especially Mohammed Awal Khalililahi, Barbra Oduro and Opoku Faustina for their unflinching words of encouragement and financial support. Finally, giving credence to scientific authority and making efforts to obtain knowledge and rationality, I thank all the authors and publishers whose work were used as literature to reference this study. iii University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES TABLE OF CONTENT Contents DECLARATION.......................................................................................................................................... i DEDICATION............................................................................................................................................. ii ACKNOWLEDGEMENT ......................................................................................................................... iii TABLE OF CONTENT ............................................................................................................................. iv LIST OF FIGURES ................................................................................................................................... ix LIST OF TABLES ...................................................................................................................................... x LIST OF ABBREVIATIONS ................................................................................................................... xi ABSTRACT ...............................................................................................................................................xiii CHAPTER ONE ......................................................................................................................................... 1 INTRODUCTION ....................................................................................................................................... 1 1.1. Background of The Study........................................................................................................... 1 1.2. Problem Statement ...................................................................................................................... 6 1.3. Purpose of The Study .................................................................................................................. 9 1.4. Specific Objectives ...................................................................................................................... 9 1.6. Significance of The Study ......................................................................................................... 10 1.7. Operational Definitions ............................................................................................................ 11 CHAPTER TWO ...................................................................................................................................... 12 THEORETICAL FRAMEWORK AND LITERATURE REVIEW ................................................... 12 2.1. Philosophical underpinning ..................................................................................................... 12 2.2. Search for theoretical framework ........................................................................................... 12 2.3. Theory of Planned Behaviour .................................................................................................. 13 2.3.1. Attitude towards the behaviour ....................................................................................... 14 2.3.2. Subjective norms ............................................................................................................... 14 2.3.3. Perceived behavioral control ............................................................................................ 15 2.3.4. Behavioral intention .......................................................................................................... 16 2.3.5. Behaviour ........................................................................................................................... 16 2.4. Justification for the TPB .......................................................................................................... 17 2.5. Literature Review ..................................................................................................................... 18 2.5.1. Literature search ............................................................................................................... 18 2.5.2. Attitudes of mother in-laws toward traditional newborn care practices ..................... 18 iv University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 2.5.3. Beliefs of mother in-laws about traditional newborn care practices (Subjective norms) 24 2.5.4. Perceived behavioural control of mother in-laws about traditional newborn care practices 31 2.5.5. Behavioural intention of mother in-laws about traditional newborn care practices .. 33 2.5.6. Behaviour of mother in-laws about traditional newborn care practices ..................... 35 2.6. Summary of Literature Review ........................................................................................... 39 CHAPTER THREE .................................................................................................................................. 41 METHODOLOGY ................................................................................................................................... 41 3.1. Study approach and Design ..................................................................................................... 41 3.2. Study Setting .............................................................................................................................. 42 3.3. Target Population ..................................................................................................................... 44 3.4. Inclusion Criteria ...................................................................................................................... 44 3.5. Exclusion Criteria ..................................................................................................................... 44 3.6. Sampling Technique and sample size ...................................................................................... 44 3.7. Data Collection Tool ................................................................................................................. 45 3.9. Data Management and Analysis .............................................................................................. 47 3.10. Methodological Rigor (Trustworthiness) ............................................................................ 48 3.11. Ethical Considerations .......................................................................................................... 49 CHAPTER FOUR ..................................................................................................................................... 51 RESULTS/FINDINGS .............................................................................................................................. 51 4.1. Demographic Characteristics of Participants ........................................................................ 51 4.2. Thematic content analysis structure ....................................................................................... 51 4.3. Attitudes of mother in-laws towards Traditional Newborn Care (TNC) practices ............ 52 4.3.1. Positive appraisal towards Traditional Newborn Care practices ................................. 53 4.3.2. Negative appraisal towards Traditional Newborn Care practices ............................... 55 4.3.3. Uncertainty about TNC .................................................................................................... 56 4.4. Beliefs of mother in-laws about Traditional Newborn Care (TNC) practices (SN) ............ 57 4.4.1. Perceptions about newborn care...................................................................................... 57 4.4.2. Spirituality about newborn care ...................................................................................... 62 4.4.3. Traditional norms about newborn care .......................................................................... 64 4.5. Perceived behavioural control of mother in-laws about TNC practices .............................. 65 4.5.1. High perceived control about newborn care practices .................................................. 65 4.5.2. Low perceived control about newborn care ................................................................... 67 v University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 4.6. Intentions of mother in-laws towards TNC practices ............................................................ 68 4.6.1. Plans before birth of baby ................................................................................................ 69 4.6.2. Plans after birth of baby ................................................................................................... 71 4.6.3. Change of plans after birth of baby................................................................................. 72 4.7. Behaviour of mother in-laws on TNC practices ..................................................................... 73 4.7.1. Use of herbal concoctions on newborn baby ................................................................... 74 4.7.2. Cleanliness of newborn baby ........................................................................................... 75 4.7.3. Feeding of newborn baby ................................................................................................. 77 4.7.4. Maintaining body warmth of newborn ........................................................................... 79 4.8. Knowledge of mother in-laws on Essential Newborn Care (ENC) practices ....................... 79 4.8.1. Health information on Essential Newborn Care (ENC) practices ................................ 80 4.9. Authority of mother in-laws over newborn care practices .................................................... 81 4.9.1. Decision about newborn care ........................................................................................... 82 4.9.2. Societal pressure on newborn care .................................................................................. 82 4.10. Summary of findings ............................................................................................................. 83 CHAPTER 5 .............................................................................................................................................. 86 DISCUSSION OF FINDINGS ................................................................................................................. 86 5.1. Demographic characteristics of participants .......................................................................... 86 5.2. Attitudes of mother in-laws towards Traditional Newborn Care (TNC) practices ............ 87 5.3. Beliefs of mother in-laws about Traditional Newborn Care (TNC) practices (SN) ............ 92 5.4. Perceived behavioural control of mother in-laws TNC practices ......................................... 99 5.5. Intentions of mother in-laws towards TNC practices .......................................................... 102 5.6. Behaviour of mother in-laws on traditional newborn ......................................................... 105 5.7. Knowledge of mother in-laws on Essential newborn care (ENC) practices ...................... 110 5.8. Authority of mother in-laws over TNC practices ................................................................. 112 5.9. Summary .................................................................................................................................. 114 CHAPTER 6 ............................................................................................................................................ 115 SUMMARY OF THE STUDY, IMPLICATIONS, LIMITATIONS, CONCLUSION AND RECOMMENDATIONS ........................................................................................................................ 115 6.1. Summary of the study ............................................................................................................. 115 Implications ......................................................................................................................................... 117 6.1.1. Implication for nursing and midwifery practice .......................................................... 118 6.1.2. Implications for nursing and midwifery research ........................................................ 118 vi University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 6.1.3. Implications for nursing and midwifery administration ............................................. 119 6.1.4. Implications for nursing and midwifery education ...................................................... 119 6.2. Limitations of the study .............................................................................................................. 119 6.3. Recommendations ................................................................................................................... 120 6.3.1. Ministry of Health (MOH)/ Ghana Health Service (GHS) .......................................... 121 6.3.2. District Health Management Team (DHMT), Daboya ................................................ 122 6.3.3. Non-Governmental Organizations (NGOs) .................................................................. 123 REFERENCES .............................................................................................................................................. 124 Appendix A: Ethical Clearance ............................................................................................................. 144 Appendix B: introductory Letter........................................................................................................... 145 Appendix C: Interview Guide ................................................................................................................ 146 Appendix D: Consent Form ................................................................................................................... 148 Appendix E: General Profile .................................................................................................................. 150 Appendix F: Codes and Descriptions .................................................................................................... 151 vii University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES LIST OF CHARTS 1.2.1. Child mortality trend in Ghana……………………………………………… 8 viii University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES LIST OF FIGURES 2.2.1. Theory of Planned Behaviour……………………………………… 17 ix University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES LIST OF TABLES 4.1. Thematic content Analysis structure ………………………………. 52 x University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES LIST OF ABBREVIATIONS TNC Traditional newborn care ANC Antenatal Clinic PNC Postnatal Clinic NGD North Gonja District GHS Ghana Health Service MOH Ministry of Health W.H.O. World Health Organization LMICs Low-and-Middle-Income Countries NGO Non-Governmental Organization GDHS Ghana Demographic and Health Survey UNICEF United Nations Children’s Fund PCB Perceived Behavioural Control ENC Essential Newborn Care GSS Ghana Statistical Service NMR Neonatal Mortality Rate GMHS Ghana Maternal Health Survey TPB Theory Planned Behaviour xi University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES UN-IGME United Nation Inter-agency Group for Child Mortality Estimation MDG’s Millennium Development Goals PHC Population and Housing Census IRB Institutional Review Board NMIMR Noguchi Memorial Institute for Medical Research xii University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES ABSTRACT Majority of neonatal morbidity and mortality occur within the first week of life which is attributed to poor care practices provided by informal caregivers at home. Among the plethora of literature read, studies have indicated that non-adherence to standard newborn care practices at home and socio-cultural factors contributed to the crawling decrease in newborn morbidity and mortality. It was observed in the North Gonja district population that, women in labor attend health facilities accompanied by their mother in-laws. Therefore, this study explored the planned behaviour of mother in-laws about traditional newborn care practices in the North Gonja District, using the Theory of Planned Behaviour as an organizing framework. An explorative descriptive design was used. Face-to-face interviews were conducted on 14 mother in-laws who met the inclusion criteria. A semi-structured interview guide through purposive sampling technique was used to collect data. Thematic content analysis was used to analyze the data after verbatim transcription of the audio taped interviews. Seven major themes were derived from the data which included; five (5) theoretic and two (2) emerged from the data. The findings suggested that mother in-laws traditionally have more authority over the care of their grandchildren even when it is against the wish of their daughter in-laws (daughter in-laws must accept their decisions on newborn care practices). The findings of the study also discovered that, mother in- laws were influenced by their traditional norms. These beliefs can be traced to their customary roots which they find difficult to avoid in the care of the newborn grandbaby. However, attention was drawn to the fact that financial constraints, inadequate health information, among others were possible factors to practice traditional newborn care. These findings of the study have implications for Nursing practice, Nursing research, and Nursing Education. xiii University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES CHAPTER ONE INTRODUCTION 1.1. Background of The Study The neonatal period is the most important and fragile phase for the survival of the newborn and the mother (GMHS, 2018; WHO, 2017). Significant developmental changes and adaptations takes place at this stage which decides the health status of the newborn. However, the very best kind of newborn care practices are neglected (WHO, 2017). Morbidity and mortality can arise from inadequate quality care during this time of a newborn’s life. According to World Health Organization (2018), newborn care practice is defined as “the immediate drying and wrapping of a newborn after birth, initiating skin-to-skin (STS) contact, clean cord care, dry cord care, immediate initiation of breast feeding and exclusive breast feeding until 6 months of age, as well as ensuring warmth (thermal control) of the newborn through delayed bathing (after 6 hours of birth) and immunization within the neonatal period”. The care provided to the newborn after birth by the family (mothers in-law) making sure the physiological, biological and psychological needs of the newborn is met. The process of rendering these services is known as newborn care practices (Bazzano, Felker-Kantor, Eragoda, Kaji, & Horlick, 2019). Most Low-and-Middle-Income Countries (LMICs) in the world have embraced these recommendations. However, a country like Ghana is not able to adopt the concept in totality due to the existence of traditional newborn care practices. Globally, current estimated newborn deaths are around 7,000 per day and 2.9 million per year (WHO, 2019) within the first 28 days after birth, despite the decline of under-five mortality proportions. In 2017, 2.5 million under-five children died within their first 28 days of life (neonatal period) (UN-IGME, 2019; You, New, & Wardlaw, 2017). The global under-five 1 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES mortality rate fell to 39 deaths per 1,000 live births in 2018 from 93 in 1990 and 76 in 2000 (59% and 49% decline, respectively). The neonatal mortality rate fell to 18 deaths per 1,000 live births in 2018 from 37 in 1990 and 31 in 2000 (52% and 42% decline, respectively) (UN-IGME, 2019). These children are not dying because we do not have the tools to save them but rather due to harmful traditional newborn practices. More than 80 per cent of all newborn deaths are caused by preventable and treatable conditions, including complications due to prematurity or during delivery, and infections like sepsis, meningitis and pneumonia (UNICEF, 2019; WHO, 2019). Current trends predict that close to 10 million 5- to 14-year-olds and 52 million children under 5 years of age will die between 2019 and 2030 (UN-IGME, 2019). Newborn care is an entitlement that is supposed to be enjoyed by every child as stipulated in the Conventions of the right of the child and hence should not be compromised (UN-IGME, 2019; UNICEF, 2019) A study conducted in America by Lee and Brann (2015), revealed that newborn mothers had a sense of relief by having their mothers or mothers in-law as the caretaker of their newborn babies. According to the study, grandparents were involved in the care of the newborn due to the mothers’ lack of newborn care experiences or commitment to work. Some grandparents in China either travelled to their children in America to stay for some few months to care for the newborn and the mother or the newborn and the mother in America travel to China to stay with the grandparent. Also, mothers who experience low breast milk sought advice from the grandparents on how to increase their breast milk production and the elderly told them to use formula as it was the method, she used to feed her children (Lee & Brann, 2015). A study in India indicated that, informal caregivers still apply some traditional practices that are detrimental to the newborn health and survival. It was estimated that, about 58.6% newborns were denied of initial feed (colostrum) and they developed neonatal sepsis, 73.6% newborns were fed with pre-lacteal feed, 2 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 61% newborns were fed through bottle, immediate bath after delivery was given to about 52% of the neonates (Goel, Murmu, Shah, & Chawla, 2015). The vulnerability of the newborn is common among practices such as artificial feeding, pre-lacteal feeding, discarding colostrum, unhygienic instruments used in circumcision, early bathing, and the application of cow dung on the umbilical cord. Long duration of breast feeding among infants were associated with opinions about breast feeding, self-efficacy and traditional beliefs about newborn care practices (Schafer et al., 2017). It was also estimated that, neonatal deaths account for approximately 80% in sub-Saharan Africa (You et al., 2017). Children continue to face widespread regional disparities in their chances of survival. Sub-Saharan Africa remains the region with the highest under-five mortality rate in the world. In 2018, the region had an average under-five mortality rate of 78 deaths per 1,000 live births. This translates to 1 in 13 children dying before his or her fifth birthday – 16 times higher than the average ratio of 1 in 199 in high-income countries (UN-IGME, 2019). One such preventable cause of death is poor newborn care practices and could be prevented by a skilled informal caregiver in the immediate postnatal period. This phenomenon, though predominant in Low and Middle Income Countries (LMICs), does not uniformly affect all countries (Afolabi, 2017). Sub-Saharan Africa will have 33% of the births and 60% of the deaths in 2030, compared with 25% and 50% in 2013, respectively (Liu et al., 2015). Traditional beliefs are handed over from generation to generation which constitute a portion of the community’s norms. These beliefs include shared values, attitudes, learned customs and behaviours. There are still common traditional practices in some societies during the care of the newborn which indirectly affects the newborn morbidity and mortality. These morbidity and mortality occurs due to inadequate knowledge of newborn care among informal or their harmful 3 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES traditional practices (Sivri & Karatas, 2015). According to Kokebie, Aychiluhm, and Degu (2015), newborn deaths are high during the newborn period because of unregistered newborn deaths at home and traditional practices such as late initiation of breastfeeding by grandmothers. The proper development of a healthy newborn depends on the care it receives in the early periods of life. Until now, neonatal care was neglected by professionals and stakeholders in Low and Middle Income countries (LMICs) which led to about 70% of infant mortality (Kokebie et al., 2015). A study in Nigeria revealed that 14.5% of mothers initiated breastfeeding within one (1) hour after birth whiles 75% initiated pre-lacteal feeding after birth. It was also revealed that 22.4% of mothers practice infant feeding adequately (Sanusi, Leshi, & Agada, 2016). This implies that, newborn survival is still a challenge in developing countries due to home delivery and care of the newborn by informal caregivers. Neonatal morbidity and mortality are usually attributed to harmful traditional practices at home in the care of the newborn. However, reduction in newborn illness and deaths from harmful traditional newborn care practices in rural communities can be achieved through a change in the beliefs and perceptions of informal caregivers towards newborn care practices (Goel et al., 2015). Despite the improvement of maternal and child health (Kelly, McHugh, & Aiken, 2012) services in Afghanistan, there are still low newborn health care services (9%) in current years (Akseer et al., 2016). There was little change in preparation for newborn care and initiation of breastfeeding within one hour after birth despite improvement in mothers’ knowledge (Edmond et al., 2018). A study in Kenya, revealed that, it is the sole responsibility of mothers and mother in-laws at home to provide quality and effective nurturing care, security and safety to improve neonatal health outcomes in promoting essential newborn development. Newborn deaths can be reduced by 25% 4 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES by community mobilization interventions, through the provision of essential home care by informal caregivers (Lassi & Bhutta, 2015). The prevalence of essential newborn care practices was very low (24%) in southern Ethiopia due to traditional beliefs and the influences of grandmothers in the care of the newborn at home (Chichiabellu, Mekonnen, Astawesegn, Demissie, & Anjulo, 2018). A study conducted in rural Zimbabwe revealed that mother in-laws influenced mothers to use existing traditional breastfeeding practices (Muchacha & Mthetwa, 2015). In Ghana, the neonatal mortality (NMR) rate for the preceding five years is 29 deaths per 1,000 live births, 2.2 times the post-neonatal rate (GDHS, 2014). Some traditional beliefs in most Ghanaian communities that contribute to the increased number of newborn morbidity and mortality include delayed initiation of breastfeeding, early exposure and bathing of the newborn after birth, application of substances on the cord. Despite the implementation of the National Health Insurance Scheme (NHIS) policy in 2008 to cover the provision of ante-natal, infant delivery and post-natal care, the rate of reducing mortality among newborns has been very slow (GDHS, 2014). Under-5 mortality is high in the Northern, Upper West, and Ashanti regions of Ghana (GDHS, 2014). Regionally, under-5 mortality ranges from 42 deaths per 1,000 live births in Greater Accra region to 78 deaths per 1,000 live births in Upper West region (GMHS, 2018). These variations can be attributed to different traditional beliefs in Ghanaian communities. According to Diji et al. (2016), socio-cultural influences to introduce artificial feeding and the perceptions of mothers being that breastmilk was not enough for the newborn growth and development hindered the practice of essential newborn care. Similar study in Ethiopia expounds that, potential harmful practices that exposes the newborn to infection include cutting the cord with sharp grass and the application of cow dung, ash, oil or butter on the umbilical cord stump. 5 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES All these are being practiced in most communities (Amare, 2014). In the northern part of the country, the mother in-law is the most relevant decision maker in terms of seeking for health care for the mother and especially the newborn without even the consent of the couple. Majority of LMICs including Ghana have not fully adopted the World Health Organization protocols in newborn care. Newborns are the highest vulnerable group of individuals, for their interval between sickness and death can be a short period. Empirical evidence suggests that the leading cause of newborn deaths is neonatal infection, 44% (2·761 million) died in the neonatal period (Liu et al., 2015). Non-adherence to standard newborn care practices among informal caregivers at home contributed to an increase in newborn morbidity and mortality. It was also observed in the North Gonja district population that, women in labor attend health facilities accompanied by their mother in-laws. It is therefore imperative for mother in-laws to recognize and strategize for the care of a newborn at home. These activities are required to deal with a number of factors such as hindering harmful traditional beliefs and cultural practices on the newborn. This study therefore, explored planned behaviour of mother in-laws about traditional newborn care practices in the North Gonja District. The Theory of Planned Behaviour (TPB) which is a human social behaviour model with implications for human behaviour and traditional norms was used as an organizing framework to explore planned behaviour of traditional newborn care practices among mother in-laws which is more likely to reveal other factors influencing newborn care practices. 1.2. Problem Statement Majority of neonatal morbidity and mortality occur within the first week of an individual life (GMHS, 2018), which is attributed to poor care practices provided by informal caregivers at home. Newborn deaths occur at home due to several factors after delivery. Socio-cultural factors 6 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES influence mothers to engage in some detrimental newborn care practices which contributes to newborn morbidity which in turn affects their survival. In Ghana, statistics showed that, there is an estimated infant mortality rate of 41 deaths per 1,000 live births and under-5 mortality is slightly higher at 60 deaths per 1,000 live births in 2014 (GDHS, 2014). At these levels, one in every 24 Ghanaian children dies before reaching age 1, and one in every 17 does not survive to his or her fifth birthday. Infant mortality has declined by 28 percent since 1998, while under-5 mortality has declined by 44 percent over the same period. The neonatal mortality rate for the preceding five years is 29 deaths per 1,000 live births, 2.2 times the post-neonatal rate (GDHS, 2014). According to the GMHS (2018), infant mortality has declined by half from 77 deaths per 1,000 live births in 1988 to 37 in 2017. During the same time period, under-5 mortality has decreased threefold from 155 to 52 deaths per 1,000 live births. The neonatal mortality rate is 25 deaths per 1,000 live births making up 68% infant mortality and 48% under-five mortality. Neonatal mortality has remained stagnant since 2007. At these mortality levels, 1 in every 19 Ghanaian children does not survive to their fifth birthday (GMHS, 2018). Poor newborn care practices among other factors contributed to the slow reduction of neonatal mortality rate which made Ghana in the sub-Saharan Africa region not to attain the Millennium Development Goals (MDG’s) targets in the year 2015. 7 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES CHILD MORTALITY TRENDS IN GHANA 180 155 160 140 119 120 108111 100 77 80 80 66 64 57 60 60 50 52 41 4437 41 43 40 30 302925 20 0 Infant Mortality Rate Under 5 Mortality Neonatal Mortality (per 1,000 live births) Rate (per 1,000 live Rate (per 1,000 live births) births) INDICATOR 1988 1993 1998 2003 2008 2014 2017 Chart 1.2.1. Child mortality trend in Ghana Source: (GDHS, 2014; GMHS, 2018) Studies have indicated that, newborn care practices are strongly influenced by home care traditional practices by mother in-laws or grandmothers. Several factors accounts for utilization of the postnatal clinic after delivery at home; such as the place of delivery, accessibility of information by mothers’, perceived beliefs and norms, knowledge and environmental factors (Bwalya, Mulenga, & Mulenga, 2017). It was observed in the North Gonja district population that, women in labor attend health facilities accompanied by their mother in-laws. There is no documented data locally in this district to ascertain the practices of essential newborn care among mother in-laws to the understanding. In this district, majority of deliveries are done at home by the influence of mother in-laws which accounts for low institutional deliveries. However, the ideal is every birth should be attended to by a skilled caregiver, but even if all 8 RATE University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES babies are delivered in the health facilities by skilled attendants, they may be affected by traditional practices at home after discharge by mother in-law’s decisions. Anecdotal evidence elucidates that, mothers with newborns are usually less considered in terms of decision making in the North Gonja District. Choice of obtaining antenatal services, hospital delivery and care of the newborn is solely controlled by mother in-laws. Although, mothers with newborn may wish to access these services, and once the mother in-law objects it, that intention ends there. Therefore, the mother in-laws have a role in certain areas of newborn care practices at home. Thus, this study explored the factors influencing the planned behaviour of mother in-laws abouts traditional newborn care practices in the North Gonja District. 1.3. Purpose of The Study The purpose of the study was to explore the factors influencing the planned behaviour of mother in-laws about traditional newborn care practices in the North Gonja District. 1.4. Specific Objectives The specific objectives were derived from the constructs of the Theory of Planned Behaviour. These specific objectives were to; 1. Describe the attitude of mother in-laws towards traditional newborn care practices 2. Assess the beliefs of mother in-laws towards traditional newborn care practices (subjective norms) 3. Determine the perceived control behaviour of mother in-laws on traditional newborn care practices 4. Ascertain the intention of mother in-laws towards traditional newborn care practices 9 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 5. Describe the behaviour of mother in-laws towards traditional newborn care practices 1.5. Research Questions In achieving the objectives above, the following research questions were investigated 1. What are the attitudes of mother in-laws towards traditional newborn care practices? 2. What are the traditional beliefs of mother in-laws towards traditional newborn care practices (subjective norms)? 3. What are the perceived control behaviours of mother in-laws on traditional newborn care practices? 4. What are the intentions of mother in-laws towards traditional newborn care practices? 5. What are the behaviours of mother in-laws towards traditional newborn care practices? 1.6. Significance of The Study The findings from this study would be of great relevance to policy and practice; it would provide relevant information to the district health directorate, healthcare providers, decision makers, Non-Governmental Organizations (NGO’s) and researchers to design a newborn care strategies or to find solutions to harmful neonatal care practices based on the findings of this study; It will help to improve household practices through Basic Essential Newborn care and influence the community to adopt good essential newborn care practices in order to achieve the universal sustainable goals, thus, reducing neonatal illnesses and deaths. It will also augment the pool of data needed by national and international health agencies and this will also serve as additional knowledge to the already existing body of knowledge in Nursing. Newborn practices that are 10 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES healthy would be promoted. The outcome would certainly contribute to the limited literature on planned behaviour of mother in-laws about traditional newborn care practices. It is in light of these that, this study aimed at exploring planned behaviour of mother in-laws about traditional newborn care practices in the North Gonja District. 1.7. Operational Definitions • Newborn/neonate: From birth to 6 months of an individual life after birth. • Newborn care: It is physiological, psychological and physical care provided to an individual within the first 28 days of life after birth in the community. • Mother in-law: it denotes a newborn baby paternal grandmother who is very closely attached to the newborn and responsible for their daily care and support at home without any formal training on how to care for the newborn. • Tradition: A socio-cultural belief or an inherited customary pattern of thoughts or behaviour of a particular group of people. • Traditional new born practices: A person’s socio-cultural beliefs, taboos or rituals used in the care of the newborn. 11 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES CHAPTER TWO THEORETICAL FRAMEWORK AND LITERATURE REVIEW This chapter discusses the theoretical framework and review of relevant literature used for the study. The theoretical framework was described first followed by the literature review. The literature was reviewed based on the research objectives of the study and the constructs of the selected theory. 2.1. Philosophical underpinning 2.2. Search for theoretical framework In the search of relevant theories to be applied in this study, four (4) theories were retrieved and reviewed from relevant data bases. Theory of Reasoned Action (TRA), which was propounded in 1975 by Martin Fishbein and Icek Ajzen to predict an individual's intention to engage in a behavior at a specific time and place. The theory was intended to explain all behaviors over which people have the ability to exert self- control. The TRA has been used successfully to predict and explain a wide range of health behaviors and intentions including smoking, drinking, health services utilization, breastfeeding, and substance use, among others (Ajzen & Fishbein, 1980). The Theory of Reasoned Action (TRA) was not considered in this study because it was not able to fit and address the research problem of the study. The Health Believe Model (HBM) by Nola Pender, identifies cognitive and Perceptual factors as major determinants for health promoting behavior. The Pender model has three major components: individual characteristics and experiences, behavior-specific cognitions, and behavioral outcome (Peterson & Bredow, 2019). This model was also not considered because it 12 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES is used for patients' responses to symptoms and compliance with medical treatments. Therefore, it will not fit well into the study. The Health Promotion Model (HPM), identifies background factors that influence health behavior. Humans are viewed holistically, but parts can be studied in the context of the whole. Human beings interact with their environment and shape it to meet their needs and goals. Individuals seek to actively regulate their own behavior (Pender, 2011). This model was also not suitable for the study because health professionals constitute a part of the interpersonal environment, which exerts influence on persons throughout their lifespan. Among the above reviewed theories, the TPB was suitable for the study because its constructs were more useful in addressing the research problem. 2.3. Theory of Planned Behaviour Theory of Planned Behaviour (TPB) as a framework was used by the researcher to explore the planned behaviour of traditional newborn care practices among mother in-laws. This conceptual framework was planned after a far-flung review of various literature on traditional newborn care practices. The purpose of this conceptual framework was to get a broader understanding of the concepts of the TPB relating them to planned behaviour of traditional newborn practices among mother in-laws. Icek Ajzen in 1985 developed the TPB from the Theory of Reason Action (TRA) after an extensive review process. This theory links beliefs and behavior. The beliefs used are attitude, subjective norm, and perceived behavioral control (Ajzen, 1991). The theory is found to be well supported by practical proofs. Attitude toward behavior, subjective norm, and perceived behavioral control lead to one’s intentions and intention leads to a final behavior. Intents to 13 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES accomplish actions of diverse types can be projected with high precision from attitudes toward the behavior, subjective norms, and perceived behavioral control. The theory postulates that, Human behavior is controlled voluntarily by the individual; attitude about the probability that the behaviour will have a negative and positive outcomes, the normative and subjective assessment of dangers and benefits of the outcome and the ease at which to perform such behaviour influences the behavioural intention; the ability and intention influences behavioural outcomes; the theory gives different meaning to normative, behavioral, and behavioural control; there should be a correlation between an actual behaviour performed or not and an individual intention to accomplish a health behaviour (Ajzen, 1991). 2.3.1. Attitude towards the behaviour To begin with, the attitude toward the behavior is the level to which an individual assesses a behaviour consequence (Ajzen, 2015). It involves a thoughtful deliberation of the consequences in accomplishing a behaviour. If the individual thinks his or her attitude will result in good (the consequences), then the person’s attitude will appear to be good about the behaviour, and if the attitude will result in something bad (the consequences), then they will be bad about the behaviour. This represents the opinions, beliefs, likes, and dislikes of an individual regarding newborn care practices (Fishbein & Ajzen, 2005). “What will happen if I engage in this behavior? Is this outcome desirable or undesirable?” 2.3.2. Subjective norms The second antecedent to behaviour known as subjective norm, is the perceived pressure exerted by the society to carry or not to carry out a certain behavior. It is the traditional codes of behavior in a particular group of people. Subjective norms are considered normative, or standard, in a 14 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES group of people. The aid family members, friends and other significant others render to a person is related to the normative beliefs (Ajzen, 2015). It represents an individual's perception of key peoples’ beliefs that encourages or discourages mother in-laws from practicing traditional newborn care practices. Mother in-laws’ beliefs about whether significant people approve or disapprove of traditional newborn care practices is in accordance to the standards of the community. “Do I want to do what they tell me?” what I’m about to do, is it in accordance with the beliefs in the community?” 2.3.3. Perceived behavioral control This construct of the theory was added later, and created the shift from the Theory of Reasoned Action to the Theory of Planned Behavior (Ajzen, 1991). The ability to perceive the easiness or difficulty in carrying out a behaviour reflecting upon the past experiences and future consequences is known as perceived behavioural control. Control beliefs are related to the perceived presence of factors that will either facilitate or prevent the behavior (Ajzen, 2015). Individual perceptions about not having enough resources, capabilities or skills even if they have positive attitude towards the outcome of the behaviour and with the believe that significant people would support the behaviour may not develop a good behavioural intention to perform the behaviour. A person may have varied perception of the behavioural control depending on the situation at hand. Behavioural intentions can be influenced directly or indirectly by a person’s perceived control behaviour (Ajzen, 2015). It represents mother in-law’s perceived difficulty or ease of practicing traditional newborn care practices. “Can I wake up early in the mornings to bath this baby? 15 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 2.3.4. Behavioral intention A behaviour would be performed depending on an individual’s intention or readiness to carry out that action (Ajzen, 2015). A behaviour is more likely to be performed if the intention to perform that behaviour is stronger, usually influenced by motivational factors (Ajzen, 1991). A person may consider the consequences of a behaviour before being involved or not involved in those actions yet to be performed (Ajzen, 1985). This explains that, before a mother in-law engages in a form of newborn care she has to thoroughly think about available options at her disposal. Also, mother in-laws’ intentions here may be driven by the motivational factors in order to be able to practice traditional newborn care. 2.3.5. Behaviour Behavioral beliefs are the subjective probability that a specific behavior will produce a given outcome. The outcome or action of a specific behaviour is influenced by a possibility of the behavioural beliefs (Ajzen, 2015). When one is able to carry out a thought at a certain period, it is known as behaviour. It represents the outcome or results of a mother in-law’s actions towards newborn care practices. Behaviour depends on one’s attitude, beliefs, perceived control, and behavioural intentions. Whether or not a person intends to perform a health behavior should correlate with whether or not they actually do the behaviour (Ajzen & Fishbein, 1980). This is to ascertain whether mother in-laws are engaged in traditional newborn care practices. 16 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Figure 2.1.1: An adapted Theory of Planned Behavior (TPB), (Ajzen, 1991) 2.4. Justification for the TPB In performing newborn care practices, attitude towards behaviour of every mother in-law depends on their personal values and beliefs. The decision to carry out or not to carry the behaviour depends on the positive attitude or negative attitude (respectfully) of the mother in- law. The beliefs and opinions of significant others about traditional newborn care practices have a significant influence on how the mother in-law will engage in the behaviour. If the mother in- law is motivated by what others are telling her, she will form the intention to practice it. Societal norms can however put pressure on the mother in-law to indulge in the behaviour whether she has evaluated it positively or not and whether she finds it easy or not easy to engage with the traditional new born care practices. Based on these, the researcher wishes to explore how attitudes, subjective norms, perceived behavioural control and intentions affect planned behaviour of mother in-laws about traditional newborn care practices. 17 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 2.5. Literature Review 2.5.1. Literature search In order to achieve a flung-far English written literature to support this study, relevant databases were used as search engines including, Cumulative Index for Nursing and Allied Health Literature (CINAHL), Google scholar, Science Direct, Google search, PubMed, Sage, SCOPUS and MEDLINE. Key words used for the search included; beliefs, perceptions, planned behaviour, tradition, newborn, practices, attitudes, subjective norms, intention, behaviour, mother in-laws and grandmothers. The literature review was organized according to the objectives of the study. English language literature from 2011 to 2021 were used for the literature review. However, older studies were included due to important information related to the study. 2.5.2. Attitudes of mother in-laws toward traditional newborn care practices The attitude toward the behavior is the level to which an individual assesses a behaviour consequences (Ajzen, 2015). According to Ajzen and Fishbein (1980), when an individual thinks his attitude will result in good behaviour, then the person’s attitude will appear to be good about their action, and if his attitude will result in bad behaviour, then they will be bad about their action. Evidence from literature indicates that the needs of the newborn after birth at home is usually supported by the mother in-laws with the anticipation of maintaining traditional newborn care practices. A study conducted in China suggested that mothers with newborns were encouraged to artificially feed their babies by their mother in-laws with the believe that artificial feeding is essential for newborns satisfaction (Zhang et al., 2015). Similarly, another study disclosed that artificial foods and water were important for the newborn with the belief that the babies do not 18 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES get enough breast milk for satiety with Exclusive Breastfeeding (EBF) practices (Thet et al., 2016). However, a study conducted by Vinu et al. (2014), in Erode, revealed that majority of mother in-laws caring for newborns have positive attitude in seeking for medical postnatal care for their newborns despite the influence of traditional believes that exists in the area. Majority of participants in an intervention group in the western region of Nepal were engaged in postnatal and child welfare checkups (Tiwari et al., 2014). Also, a study conducted in Democratic republic of Lao disclosed that it is the duty of the mother in-law to support primiparous mothers in the care of newborn babies very well until some few months that these young mothers can take care of their newborn babies on their own (Sychareun et al., 2016). Also, a study in South Africa revealed that newborn mothers depend on grandmothers to take care of their babies so that they can work (Horwood et al., 2019). Mothers in-law prepare their daughters towards delivery by organizing delivery items in a bag and after delivery they boil herbal concoctions for newly mothers to drink in order to stimulate breast milk production for the newborn in order to aid in the satisfaction and healthy growth of the newborn (Sychareun et al., 2016). Grandmothers administered herbal concoctions to treat their newborn babies with abdominal colic and also to make newborn babies comfortable during night (Angelo, Pontes, Sette, & Leal, 2020; Kavle et al., 2014). A study conducted in Ethiopia suggested that, herbal concoctions were given to newborn babies by informal caregivers to prevent them from falling sick (Degefie, Amare, & Mulligan, 2014). In contrast, studies from both Africa and abroad revealed that, maternal grandmothers had positive attitude for breastfeeding and were not willing to give any local substance to their newborn babies drink (Agudile, Okechukwu, Subramanian, Geller, & Langer, 2020; Mueffelmann, Racine, Warren-Findlow, & Coffman, 2015). A study conducted in 19 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Zambia and Pakistan reveled that, informal caregivers tend to seek for medical care from healthcare facilities when they do not succeed using traditional herbal treatments (Premji, Khowaja, Meherali, & Forgeron, 2014; Sivalogan et al., 2018). Grandmothers believed in giving water after breastfeeding to their newborn babies to quench their thirst than giving only breast milk (Ferreira, Piccioni, Queiroz, Silva, & Vale, 2018; Locks et al., 2015). Mothers were afraid of aspirations and deaths associated with force feeding of newborn babies and they considered this practice to be outdated to practice (Abasimi, Atindanbila, Mwini-Nyaledzibgor, Benneh, & Avane, 2014). A study by Bucher et al. (2016) revealed that, giving or applying herbal preparations on a newborn baby were outmoded and harmful to the newborn’s health. In Africa, a study conducted in Southern Sudan, revealed that grandmothers demonstrated more knowledge for keeping the newborn warm by describing wrapping of the baby, bathing the baby with warm water and allowing mothers to be closer to their babies at all times (Gee, Vargas, & Foster, 2018). This indicates that mother in-laws with more knowledge on newborn care practices performs good newborn care practices. Conversely, newborns health becomes jeopardized when traditional newborn care practices are used on them by their grandmothers with inadequate knowledge on proper newborn care practices (Amolo, Irimu, & Njai, 2017; Degefie et al., 2014). However, mothers in-law possessing knowledge about newborn care practice, is usually not an assurance that they can perform the behaviour effectively (Campos, Chaoul, Carmona, Higa, & Vale, 2015). The attitudes of most mother in-laws are inclined to their traditional beliefs, who finds it difficult to do away with such beliefs irrespective of their educational level. Hill, Scheelbeek, Hamza, Amare, and Schellenberg (2020) discovered in their study that, it was culturally accepted by all grandmothers to practice delayed bathing of their newborn 20 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES grandchildren by resorting to the use of oil to rub the newborn baby’s body. In Nigeria, Adejuyigbe et al. (2015) revealed that, immediate bathing of newborn babies after delivery by their grandmothers is believed to remove blood stains on the newborn body. Also, grandmothers indicated that, the newborn baby is always dirty with maternal blood and especially visible vernix was believed to be semen. Majority (98.2%) were bathed immediately after delivery by their grandmothers to remove blood stains and dirt (Adelaja, 2011). In Bangladesh, newborn babies were given immediate bathing to remove vernix from their bodies in order to prevent them from developing body odour later in life (Hunter et al., 2014). However, studies conducted by Shamba et al. (2014) and Dhingra et al. (2014), revealed that it was considered normal in Tanzania among mother in-laws to cover their newborn grandbabies immediately after delivery in order to preserve their body warmth by delaying bathing. In India, newborn babies were rubbed with oil every day after bath (Jenifer & Benjamin, 2019). According to Hollowell et al. (2019) , a study conducted in rural Burkina Faso, suggests that apart from bathing the newborns, mother in-laws also teach these mothers on how to effectively breastfeed their babies and how to identify newborn danger signs for quick treatment response. A systematic review conducted on the influence of grandmothers about breastfeeding practices revealed that, majority of grandmothers had positive appraisal about breastfeeding their newborn grandbabies due to their previous experiences and traditional beliefs and as such they valued breastfeeding for their newborn grandchildren (Ferreira et al., 2018; Negin, Coffman, Vizintin, & Raynes-Greenow, 2016). Equally worth noting is the evidence from literature that indicates that taking care of a newborn baby in the Ghanaian context is held in high esteem by mother in-laws, especially their first grandchildren. The days after birth in rural communities where community health care providers 21 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES were inadequate to go for home visiting, mother in-laws became the sole care providers for the newborn from any form of health hazards (Gupta et al., 2015). In relation to mother in-laws’ attitude towards newborn care, they assist to provide psychological, physical assistance and emotional care for their daughter in-laws and their newborns in their natal periods (Aubel, 2012; Moyer et al., 2012). In providing support for the new parents, grandmothers coerce parents from practicing suggested essential newborn care practices by healthcare professionals. The traditional practices initiated by grandmothers for preterm babies have some harmful effects on the health of the newborn (Adama, Bayes, & Sundin, 2018). Grandmothers were willing to immediately send their newborn grandchildren to nearby health care facilities when the babies are ill despite their beliefs and practices associated with newborn care practices at home (Jenifer & Benjamin, 2019). Also, when it comes to newborn care, mothers have a double sense of responsibility to meet both health system and traditional newborn care goals (Buser et al., 2020). In Northern Ghana, mother in-laws act as substitutes for healthcare providers in proving healthcare information for the newborn and their mothers. Essential newborn care practices that are recommended by healthcare professionals to grandmothers who care for these newborn babies at home are being rejected and not paid attention to (Moyer et al., 2012). Mother in-laws believe in in the advice of grandmothers on traditional newborn care practices to be good for the wellbeing of newborn babies than the advice of the healthcare provider (Degefie et al., 2014). They believe that those practices were handed over to them by their predecessors and as such they will continue to honour them with those practices. They also believe that, the child may grow-up to be physically weak if they employ the hospital protocols for the care of the newborn baby. Contrary, most maternal education on newborn born care were received during pregnancy at the antenatal clinics (Amolo et al., 2017). Majority of the participants identified professional 22 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES healthcare information on newborn care from physicians and nurses on breastfeeding (Wambach, Domian, Page-Goertz, Wurtz, & Hoffman, 2016). Another study conducted in Egypt revealed that mothers were encouraged to exclusively breastfeed their newborn babies based on health information from media health programs; local television channels (Kavle et al., 2014). A study conducted among community health workers in Afghanistan, where home visiting tend to improve the care seeking and knowledge of informal care providers about newborn care but not birth preparedness and newborn care practices (Edmond et al., 2018). Another study conducted in Southern Ethiopia among women revealed that poor access to newborn healthcare information from antenatal clinics (ANC), Postnatal clinics (PNC) and lack of information about newborn dangers signs contributed to poor coverage of essential newborn care practices (Chichiabellu et al., 2018). Another study conducted in some African countries revealed that messages on newborn care practices were mostly influenced by household elders who were traditionally inclined to their beliefs (Hill et al., 2020). Studies conducted among grandmothers in Thai and Tanzania revealed that the participants did not practice exclusive breastfeeding because they think the newborn baby cannot survive a day without drinking water and as such they gave them water to drink in the absence of their daughters in-law (Bootsri & Taneepanichskul, 2017; Falnes et al., 2011). According to Angelo et al. (2020) grandmothers discarded colostrum because they think is an old milk stored in the breast for long period. A study conducted in Northern Ethiopia and Zambia among postpartum mothers revealed that informal caregivers demonstrated knowledge on essential newborn care practices especially on EBF (Berhea, Belachew, & Abreha, 2018; Buser et al., 2020). It was reported in a study conducted in India that women were having misconceptions about colostrum to be hard to digest (Corbett & Callister, 2012). 23 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 2.5.3. Beliefs of mother in-laws about traditional newborn care practices (Subjective norms) Apart from the belief that breastfeeding increases the intellectual capabilities of the child which influences the newborn care practices behaviour of mother in-laws, their behaviours towards newborn care practices are also strongly influenced by traditional beliefs in their natural environment. According to Campos et al. (2015), mothers in-law have the belief that, offering water for their babies will quench their taste. They gave some pressure to lactating mothers to feed their newborns with breast milk. Societal pressures, traditional beliefs, gender disparities, poor health information and environmental factors are some of the hinderances for recommended newborn care practices. Societal pressure on cleanliness was a hindering factor for early bathing of the newborn (Bazzano et al., 2019). A crucial evidence in literature found in China indicates that, majority of newborns are properly fed by their mothers than their grandmothers and majority of these children are nursed using traditional beliefs by these grandmothers which is causing infant malnutrition. They depend on their personal experiences and significant others to influence some of their newborn care behaviour (Yue et al., 2018). Also, a study conducted among Chinese-USA based on newborn mothers indicates that breast-feeding mothers rely heavily on grandmothers support, especially the eldest female (Scott, Shreve, Ayers, & McElfish, 2016). According to Nisha, Raynes- Greenow, Rahman, and Alam (2019), a study conducted in rural Bangladesh, suggests that delaying in seeking for healthcare is influenced by mothers in-law by separating mothers and newborns for a particular period in different rooms. This was believed to prevent the newborn from “eyes of bad spirit”. Also, studies conducted in India revealed that, informal caregivers held the belief that newborn babies and their mothers were protected from evil spirits by not allowing 24 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES them to come out of their rooms especially during evening, until some days. Before the newborn babies are allowed to come outside the rooms, ceremonial rituals are performed to initiate them (Bangari, Thapliyal, Aggrawal, & Sharma, 2019). It was reported in a study conducted by Sharma, van Teijlingen, Hundley, Angell, and Simkhada (2016) that women with newborn babies were housebound for a period of days before they were allowed to go out. In Greece, birth customs include women and babies resting and being isolated for 40 days after birth, a period that is still observed (Eastman, 1940). Also, in India, among Muslims, the postnatal seclusion last for a period of 40 days (Bandyopadhyay, 2009). A study conducted in Zambia revealed that it was a traditional norm for newborn babies to be indoors for about 2 weeks to 3 months period (Sivalogan et al., 2018). In Africa, preferences and opinions of a mother in seeking for skilled maternal and child health care is mostly decided by the mother in-law (Altaye et al., 2018). Traditionally, where a mother in-law don not live with the newborn parents in the same house, they relocate to their children’s house before or after delivery of their grandchild. Sometimes mothers with newborn babies are also moved to stay with mother in-laws. In any of these, it is a usual practice to initiate traditional newborn care practices by the mothers in-law with the belief that grandmothers are the custodians of traditional newborn care practices (Aubel, 2012). A study conducted by Angelo et al. (2015) revealed that, grandmothers support for their daughters in-law were influenced by societal pressure and their previous experiences on newborn care. They helped their daughters in-law in their house chores, and they were also the source of information for the care of the newborn to their daughters in-law. Traditional beliefs of mothers in-law in the care of the newborn may result in the delay of some newborn care practices resulting in adverse health problems of the newborn (Adama et al., 2018; Osman, Gaffer, Sharkawy, & Brandon, 2018). 25 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Additionally, a systematic review study suggests that mothers in-law have good influences on newborn care practices such as EBF practices on newborn mothers (Negin et al., 2016). Mother in-laws are some of the most influential people in the selection of newborn care practices at homes. They are the sole and most influential health advisors for their daughters in-law during delivery and the newborn period (Mukunya et al., 2019; Sharkey et al., 2017). Mothers in-law traditional beliefs and conflicting advice have contributed to the decrease in maternal self- confidence in the care of the newborn baby (Bazzano et al., 2019; Zhang et al., 2015). Mother in- laws superstitious beliefs are some of the challenging factors to the care of the newborn with low birth weight. They have the belief that, there are always delivery complications associated with giving birth to a normal birthweight or high birthweight newborns (Nisha et al., 2019). Similarly, a study in Zambia indicated that, grandmothers with more distinctive traditional alignment interferes more in their grandchildren wellbeing (Sichimba, Mooya, & Mesman, 2017). A study conducted in the city of Goiania revealed that in the early and late postnatal periods are influenced by the traditional norms (Oliveira, Iocca, Carrijo, & Garcia, 2015). It was reported in a study conducted in India that women were having the perception about colostrum to be hard to digest and it was considered as milk is “not ready” (Corbett & Callister, 2012). Also, the belief of prolong breastfeeding resulting in sagging of breast among young mothers was common in the area of study (Wanjohi et al., 2017). Many studies revealed that it was a taboo for the newborn baby to be breastfed with this type of milk (colostrum) and for that reason the breasts of newborn mothers were massaged to express and discard the colostrum (Aborigo et al., 2012; Acharya & Meena, 2016; Ahmad et al., 2012; Gupta et al., 2015; Subbiah & Jeganathan, 2012). A study among some districts in Sierra Leone revealed that mothers stopped breastfeeding their newborn babies because they were influenced by their mothers in- 26 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES law with the belief that having sexual intercourse can contaminate the breast milk and endangers the newborn’s life (Sharkey et al., 2017). However, majority of informal caretakers fed their newborn babies with colostrum with the belief that the first breastmilk contains nutrients that protect the newborn from diseases and is good for the growth and development of their babies (Agunbiade & Ogunleye, 2012; Gul, Khalil, Yousafzai, & Shoukat, 2014; Jenifer & Benjamin, 2019; Kavle et al., 2014; Nethra & Udgiri, 2018). It was reported in study conducted in Northern Ghana, where grandmothers were engaged in traditional practices to stimulate the production of breastmilk for newborn babies to be fed on (Aubel, 2021). Similarly, studies conducted in India and Brazil revealed that informal caregivers immediately fed most newborn babies after birth with animal milk, hot water and mustard oil as ancestral heritage to welcome them before initiating breastmilk (Corbett & Callister, 2012; Oliveira et al., 2015). Also, newborn mothers were confronted with inaccurate traditional beliefs about newborn care practices which made them to give herbal concoctions to their newborn babies after birth (Agunbiade & Ogunleye, 2012). Prelacteal feed was not given to majority of newborn babies as reported in a study (Devkota & Bhatta, 2011; Karmacharya, Cunningham, Choufani, & Kadiyala, 2017). A study revealed that grandmothers believed that excessive crying of newborn babies were associated with hunger due to weak or insufficient breastmilk of mothers and they attended to newborn babies by giving them artificial feeds in order to stop them from excessive cry (Angelo et al., 2020; Kavle et al., 2014). Majority of mothers with newborn babies who lived with grandmothers started breastfeeding within the first hour after birth. It was culturally accepted by all grandmothers to welcome newborn babies with breastmilk as they belief it is the only food for the newborn baby (Karmacharya et al., 2017). Studies in Thailand and in Ghana indicated that, welcoming of the 27 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES newborn baby by reciting Azan (Islamic call for prayers) into the ears of the newborn (Zeyneloğlu & Kısa, 2018) and putting the Islamic books under the pillow of the newborn baby (Ratanasombat, 2008) were common practices in Muslim communities. It is reported in a study that, a key obstacle to institutional delivery was the denial of Azan by religious leaders to welcome newborn babies (Ababor et al., 2019). In India, shaving the head of the newborn on the 40th day was one of the Islamic rituals with the belief that newborn baby hair would grow to replace the vagina which was believed to be unclean (Bandyopadhyay, 2009). Also, shaving the newborn baby’s intrauterine hair signifies a ritual called ‘aqiqa’ which is performed on the newborn baby to confer protection against evil spirits (Benkheira, 2017). Similarly, findings from a previous study revealed that the newborn male child’s hair is shaved at a shrine to prevent the shadow of the evil spirits of the baby in order to prevent future predicaments (Mohyuddin & Munir, 2015). According to Dumbaugh et al. (2014), in the Ghanaian context, mothers in-law are the sole decision makers and care takers of newborn babies and for that reason mothers with newborn babies stay with them or travel to their maternal home. Majority of couples cannot make decisions together concerning their newborn babies until authority is handed over to them by their respective mothers. A study in Northern Ghana revealed that grandmothers who believed in their traditional norms influences mothers to treat newborn illnesses with herbal concoctions (Moyer et al., 2016). Similarly, a study in rural Northern Ghana explicates that mother in-laws are the reservoirs of indigenous traditional practices and they inculcate these beliefs into the care of their grandchildren. Mothers in-law act as the sole care provider for the newborn after delivery (Gupta et al., 2015). 28 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES In those days, tribal marks (scarifications) were seen as means of easy identifying one’s tribe and historical migration pattern among a conglomerate of various ethnic groups who lived within the same boundaries (Cullivan, 1998). Giving tribal marks are still common in Northern Ghana among some members of Gonja, Frafra and the Mole Dagomba (Garve, Garve, Türp, Fobil, & Meyer, 2017). A study at Tamil Nadu, India revealed that, placing items at the entrance of doors was a harmless means of protecting newborn babies from evil spirits and people with evil harm (Latha, Kamala, & Srikanth, 2017). A study conducted in India indicated that, ritual ceremonies were performed using small ropes tied around the newborn baby’s neck, wrist or ankle with the belief that it confers protection to the newborn baby from evil spirits (Corbett & Callister, 2012). A study conducted in South India revealed that women caring for newborn babies believed in special rituals like putting herbal substances on the cheeks, forehead and soles, tying black thread to the hand or legs, putting amulets to the waist and abdomen to protect the newborns from evil spirits (Cacodcar, Dubhashi, & Joglekar, 2015; Jenifer & Benjamin, 2019). A study conducted in Jordan revealed that newborn babies are secluded to protect them from evil eyes from people who are envious. They held the belief that, the evil eye can transmit misfortunes to the newborn baby and as such the baby must be protect from people outside the family (Mrayan, Abujilban, Abuidhail, & Alshraifeen, 2018). Some mothers are not satisfied and have misunderstandings with their mother in-laws because they are coerced to follow traditional newborn care practices and unnecessary expectations of those traditional practices (Zheng, Watts, & Morrell, 2019). Other previous studies revealed that advice on newborn care practices from revered and authoritative grandmothers cannot be refused. Traditional newborn care practices are coordinated by these elderly women and 29 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES newborn mothers and fathers had to seek permission from paternal grandmothers in order to make decision on the health of their newborn baby (Aubel, 2021; Falnes et al., 2011; Premji et al., 2014). Mothers were compelled to accept traditional newborn care practices in order to avoid conflict between them and their mothers in-law (Jenifer & Benjamin, 2019). In Bangladesh, younger mothers lack autonomy and decision making power on the care of their newborn babies because they have to comply with decisions of their mothers in-law (Hunter et al., 2014). A study in Northern Ghana revealed that mothers in-law, soothsayers and husbands need to be consulted by newborn mothers before going to a health care facility (Moyer et al., 2014). In contrast, previous studies reported in literature revealed that other informal referent others like fathers, grandfathers and maternal grandmothers and clinicians were the sole decision makers on the care of newborn babies (Edmond et al., 2018; Ferreira et al., 2018; Odom, Li, Scanlon, Perrine, & Grummer-Strawn, 2014). A cross-sectional study revealed that fathers and maternal grandmothers were the decision makers for their newborn babies in their families. (Ferreira et al., 2018). Similarly, grandmothers and friends played a central role as advisors to their daughters in- law during pregnancy and postnatal periods and as such newborn mothers were given pressure by grandmothers as essential figures regarding newborn care practices (Agunbiade & Ogunleye, 2012; Aubel, 2012; Karmacharya et al., 2017; Wambach et al., 2016). Also, grandmothers were identified as great influencers on newborn mothers over newborn care practices (Bernie, 2014). Other studies conducted in some African countries revealed that grandmothers were influenced to care for their newborn grandchildren because it was a norm for mother in-laws to care for new member of their husbands lineage as part of their families hierarchies. Mothers and parents relied on their traditional beliefs to provide newborn care (Falnes et al., 2011; Hill et al., 2020; Sivalogan et al., 2018). A study conducted among Mexican American women revealed that most 30 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES of the participants decision on breastfeeding was influenced by traditional beliefs and values from their country (Wambach et al., 2016). Another previous study among women in India revealed that grandmothers’ decisions on newborn care were influenced by their culture and traditions (Corbett & Callister, 2012). 2.5.4. Perceived behavioural control of mother in-laws about traditional newborn care practices Empirical evidence from literature expounds that, mothers in-law in the United Kingdom (UK), are seen as important informal caregivers in newborn care practices (Emmott & Mace, 2015). A study in Thai suggests that mother in-laws who assists adolescent mothers in newborn care possess better knowledge and skills. They are able to perform newborn care practices with confidence in their previous knowledge handed over to them (Bootsri & Taneepanichskul, 2017; Premji et al., 2014). Mothers who have inadequate breast milk finds it difficult to practice EBF and those who are able to exclusively breastfeed their babies find it difficult to initiate artificial feeding (Wanjohi et al., 2017). According to Sarker et al. (2016), a study conducted in Bangladesh found that mothers in-law usually prevent their daughters in-law from seeking for maternal and child health care services at the health facilities because they themselves had never been to the hospital for Maternal and child health care services. The author also suggests that, in Bangladesh, mothers in-law are seen as important decision makers regarding the health of the newborn and the mother (Sarker et al., 2016). A study in some African countries revealed that grandmothers and older women were viewed as knowledgeable and skilled ‘the big advisor’, with a self-belief that they know how to do things properly. They were generally trusted by the mothers due to their experience, and because they were perceived as wanting the best for their families (Iganus et al., 2015). A study conducted in 31 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Nigeria indicated that, home deliveries and newborn care practices were perceived to be easy and convenient by informal caregivers (Adelaja, 2011). Mother in-laws are seen as those who possess skills, knowledge and experiences for newborn care and are accorded with some respect in society as final decision makers for newborn care. Their prescription for newborn care supersedes the formal healthcare provider with the believe that healthcare workers are not capable of caring for their grandchildren if they do not intervene (Adama et al., 2018; Aubel, 2012; Gupta et al., 2015). Mothers in-law with higher educational background and are perceived knowledgeable are less likely to be engaged in harmful traditional newborn care practices (Asare, Preko, Baafi, & Dwumfour-Asare, 2018; Thet et al., 2016). However, mothers in-law with low educational background are more likely to use potential harmful traditional practices for the care of the newborn (Khan, Memon, & Bhutta, 2013). In rural Nepal, despite the limitation of grandmothers’ exposure to nutritional related counselling, their little knowledge positively influences maternal knowledge on correct infant and young child feeding practices. About 90% of newborns were given colostrum and initial breast-feeding in the first hour after birth (Karmacharya et al., 2017). According to Mesekaa, Mungai, and Musoke (2017), study conducted in Southern Sudan found that 90% of mothers were aware of feeding the newborn on demand with breast milk. In maintaining warm temperature of the newborn, 90% of mothers wrapped the newborn with cloth and 33% were practicing kangaroo mother care, 18.2% of mothers were aware that umbilical cord should not be covered after caring for it. Vaccines were believed to be harmful to the health of the newborn among 3.4% mothers (Mesekaa et al., 2017). According to Misgna, Gebru, and Birhanu (2016), in Ethiopia about 80% of informal care givers were knowledgeable on essential 32 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES newborn care practices and 92.9% could practice essential newborn care services. The application of butter or oil on the umbilical stump were still prevalent in the area of the study Informal care takers were strongly engaged in traditional newborn care practices with ease because of their intrinsic motivation like happiness, joy and benefits of good health associated to the care of newborn babies (Gallegos, Vicca, & Streiner, 2015; Russell et al., 2016). Contrary, many informal caregivers were afraid of performing some traditional newborn practices like introduction of family foods that are capable of causing harm to babies at 6-month-old. They also had the fear that prolong breastfeeding of baby was poisonous if a mother is pregnant (Kavle et al., 2014). Grandmothers had support for newborn care practices, however other factors like cultural and financial constraints influenced their ways of newborn care practices (Ferreira et al., 2018; Locks et al., 2015). A study in Pakistan revealed that despite the love of parents for their children, fathers in Pakistan found it difficult to take care of their newborn babies because of poverty (Premji et al., 2014). A study in both rural and urban Nepal revealed that, women relied on readily available local cow or buffalo milk as a substitute for infant formula (Karkee, Lee, Khanal, & Binns, 2014). Also study conducted in the city of Caceres revealed that, mothers were able to solve breast feeding problems by introducing formula feeding to their babies because it was easily available (Oliveira et al., 2015). 2.5.5. Behavioural intention of mother in-laws about traditional newborn care practices In deciding the care for a newborn baby, grandmothers are the first point of call in the community. Provision of information and support for the newborn care is the responsibility of the grandmother in the community. As such, every grandmother intends to care for her grandchild immediately it is born. In some communities, it is the duty of the grandmother to advise the younger mother on newborn care immediately after delivery (Adama et al., 2018; 33 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Aubel, 2012). The perception the community members have about grandmothers serves a motivation for them to practice traditional newborn care for their grandchildren. Evidence from literature suggests that good social and traditional beliefs influence mothers in- law intentions towards traditional newborn care practices (Wanjohi et al., 2017). Opinions and beliefs of people in the community influence the preference of the mother in-law to seek for skilled health care for their grandchild or to practice traditional newborn care (Altaye et al., 2018). In Africa, the intentions of grandmothers to care for their newborn grandchildren are motivated by their previous experiences with the ease in carrying out the practice compared to that of the newborn mothers who have little or no previous experiences (Mukunya et al., 2019). The application of traditional substances on the umbilical cord stump is always in the interest of the grandmothers pertaining to her cultural belief (Buser et al., 2020). Mothers are encouraged by mothers in-law to breastfeed their babies with colostrum immediately after delivery with the intention of stimulating maternal breast milk production (Sychareun et al., 2016). Despite the health facilities being the first point of providing healthcare for newborns, still grandmothers interest in traditional practices supersedes the healthcare worker as she is being motivated in the community as knowledgeable. The choice to seek for healthcare for the newborn is usually decided by mothers in-law (Goel et al., 2015; Nisha et al., 2019). Also, potential harmful traditional beliefs influences the intentions of mother in-laws in the practice of traditional newborn care (Hoodmaker, 2016). However, some traditional newborn care practices are made by the newborn mothers themselves (Thet et al., 2016) The decision of a mother to traditionally care for a newborn is influenced by a grandmother who possesses strong sense of responsibility to support the growth of her grandchild. Perception of drying and wrapping practices of the newborn is influenced by the vulnerability and dirtiness of 34 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES the newborn baby (Bazzano et al., 2019; Buser et al., 2020). Also, a finding was reported in a study by Edmond et al. (2018) where mothers had changes in birth preparedness and newborn care. 2.5.6. Behaviour of mother in-laws about traditional newborn care practices In Arab societies, mother in-laws bath babies immediately after discharged from the hospital. Also, salt is applied on the skin of the newborn and left overnight before bathing the newborn the next day with the believe that the newborn baby skin will be cleaned from maternal secretions (Arabiat et al., 2019). A study in an American-Indian community suggests that the practice of application of some plants and foods to improve breastfeeding is from the perspectives of grandmothers (Houghtaling, Shanks, Ahmed, & Rink, 2018). Also, a previous study conducted in Ethiopia (Degefie et al., 2014) where participants believed that poor maternal nutrition may lead to inadequate breast milk production. In South Asia, mothers in-law’s beliefs on traditional feeding practices of the newborn including discarding colostrum and pre-lacteal feeding are some of the challenges to proper breastfeeding practices (Sharma & Byrne, 2016). A study conducted in Gilgit, Pakistan, expounds that initiation of colostrum immediately after birth and the application of oil on the umbilical cord are some of the common practices among informal caregivers (Khan et al., 2013). Several studies revealed that mothers and grandmothers expressed that colostrum was good for the growth of babies and ensured their newborn babies were breastfed with colostrum within an hour after delivery (Chhetri, Bhandari, Karna, Chaudhary, & Yadav, 2019; Gul et al., 2014; Jenifer & Benjamin, 2019). Other studies among informal care providers also revealed that breastfeeding was seen as the necessary and irreplaceable food to meet the child’s nutritional needs and as such newborn babies were not given prelacteal feeding (Angelo et al., 2020; Chhetri et al., 2019; 35 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Devkota & Bhatta, 2011). Contrary, many studies revealed that majority of newborn babies were bathed within six hours, delayed breastfeeding initiation, application of traditional substances on the umbilical cord stump, feeding newborns with pre-lacteals and discarding of colostrum were the common practices among informal care givers. Grandmothers teach newborn mothers how to feed their babies with prelacteal feeds (Bootsri & Taneepanichskul, 2017; Hunter et al., 2014; Karmacharya et al., 2017; Memon et al., 2019). Studies in Ethiopia (Degefie et al., 2014) and Nepal (Locks et al., 2015) revealed that women discarded colostrum and gave their newborn babies prelacteal feeds like water and buffalo milk before the initiation of breastmilk to their newborn babies. In addition, other studies conducted among grandmothers revealed that participants started feeding their newborn grandbabies with solid foods, herbal tea and water before their sixth month (Aubel, 2021; Ferreira et al., 2018; Nunes, Giugliani, do Espírito Santo, & de Oliveira, 2011). A systematic review of both quantitative and qualitative studies in sub-Saharan Africa indicated potential harmful traditional care practices across countries, including delayed drying and wrapping of the newborn, applying substances to the cord to make it drop off quickly; and delayed breastfeeding because babies do not show signs of hunger (Bee, Shiroor, Hill, & Nutrition, 2018). According to Gee et al. (2018) the use of herbal concoctions to treat ailments of the newborn, application of traditional substances on the umbilical cord of the newborn and mixed feeding were some of the common potentially harmful traditional practices among grandmothers in Southern Sudan. Delaying in the initiation of breastfeeding, discarding colostrum, use of mixed feeding, use of herbal concoctions to treat newborn illnesses and application of substances like shea butter, ground shea nuts, local herbs, local oil, or “red earth sand to the umbilical cord are common traditional practices which can cause potential harm to 36 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES the newborn health (Aborigo et al., 2012; Adama et al., 2018; Degefie et al., 2014; Saaka & Iddrisu, 2014; Sarker et al., 2016). Studies conducted by da Silva, da Cruz, Macedo, da Silva, and Gomes (2013) and Hanson et al. (2015) revealed that grandparent had the habit of practicing hand hygiene before caring for their newborn babies. Another study revealed that informal caretakers washed their hands before touching their newborn babies (Chhetri et al., 2019). Contrary, previous literature reported that TBAs who were attending to newborn babies after delivery had their hands uncleaned (Dhingra et al., 2014). Immediate bathing of the newborn after birth is commonly practiced by grandmothers at home (Mukunya et al., 2019). Also, studies conducted both in Africa and Abroad revealed that newborn babies were bathed immediately after delivering the placenta (Adejuyigbe et al., 2015; Degefie et al., 2014; Smittenaar et al., 2020). Contrary, Hill et al. (2020) discovered in their study that, it was culturally accepted by all grandmothers to practice delayed bathing of their newborn grandchildren by resorting to the use of oil to rub the newborn baby’s body. This finding is inconsistent with a study conducted in India (Corbett & Callister, 2012) where mothers were engaged in delayed bathing of their newborn babies for a period of 9 days or 3 months. A study in southern Tanzania suggests that, newborn babies were delayed (at least 6 hours) in their first bath, majority were not dried and wrapped within five minutes after delivery and applying nothing to the newborn umbilical cord were the common practices (Penfold et al., 2014). This study couldn’t identify extra care for newborn babies. In southern Sudan, cutting the umbilical cord with unsterile instruments, application of oil, ash, or charcoal on the umbilical cord stump, mixed feeding and use of concoctions to treat minor newborn ailments were some of the traditional newborn care practices by grandmothers (Gee et al., 2018; Reshma, 2014). Several studies revealed that newborn babies umbilical cords were kept clean 37 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES and their bodies massaged with oil after daily bath (Jenifer & Benjamin, 2019; Peterside, Duru, & Anene, 2015; Walsh, Norr, Sankar, & Sipsma, 2015). In contrast, a study conducted in India revealed that newborn babies umbilical cords were not cleaned after delivery (Smittenaar et al., 2020). Furthermore, it was reported in a study that informal care takers of newborn babies did not use any form of local remedy to treat their babies whenever they were sick, but they rather seek help from medical practitioners (Çapik & Çapik, 2014). In cutting the umbilical cord of the newborn, a clean sharp (bamboo) or razor blades washed with alcohol is used and tied with a rope, then the mother and baby is put on “hot bed” to provide some warmth for them (Sychareun et al., 2016). According to Berhea et al. (2018), in Northern Ethiopia, about 78.5% of mothers bathed their newborn babies after 24 hours of delivery, 66% of mothers wrapped their babies bodies with clean dry cloth, and 97. 4% practiced exclusive breastfeeding. However, eye care was practiced by 67.1% of mothers by applying traditional substances. These findings are consistent with previous studies (Adejuyigbe et al., 2015; Degefie et al., 2014; Jenifer & Benjamin, 2019) where newborn babies were protected from cold by bathing the newborn babies frequently with warm water and soap, placing fire in the room for the entire day to keep baby warm and wrapping newborn babies with clothes. In contrast, findings were reported in a previous studies where newborn babies were not dried and wrapped immediately after birth and immediate bathing given to newborn babies within 24 hours after delivery (Dhingra et al., 2014; Shamba et al., 2014). Recommendation from W.H.O. suggest that bathing of every newborn baby should be delayed for a period of about 72 hours in order to keep the baby warm and to prevent hypothermia (EveryNewBorn, 2014). 38 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES In Egypt, approximately 90% of home deliveries are assisted by informal caregivers which accounts for about 37.5%. About 27% of mothers initiated breastfeeding late and the use of traditional practices dominated over essential newborn practices in the care of neonatal eye and umbilical stump. These practices pose negative effects on neonatal health and should be discontinued (Osman et al., 2018). A study in Tema, Ghana, revealed that there were low exclusive breast feeding practices among mothers with newborns in northern Ghana strongly influenced by their traditional beliefs than mothers from Ga ethnic group (Asare et al., 2018). 2.6. Summary of Literature Review The plan and preparation for the care of the newborn baby by mother in-laws or grandmothers starts from the period of gestation of their daughter in-laws. These mother in-laws gather all necessary materials and information waiting for the arrival of their grandchildren and when these children are delivered successfully, they take over the care of the newborn from the birth attendant until the newborn mother can take care of the baby herself with little or no guidance. It was observed that mother in-laws with more knowledge tend to practice less harmful traditional practices on the newborn babies in some communities. In some other communities, it was the duty of the mother in-laws to support new parents in the care of their newborn babies. Mothers in-laws are mostly the sole decision makers in the care of newborn babies especially in Africa. Societal pressures, traditional beliefs, gender disparities, poor health information and environmental factors form part of the hinderances for recommended newborn care practices. Societal pressure on cleanliness was a hindering factor for early bathing of the newborn. The traditional beliefs of a particular community play a major role during the care of the newborn. 39 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Also, Grandmothers are seen as the reservoirs of knowledge for traditional newborn care practices and as such they are experienced. Hence, they are able to apply their previous experiences and skills in the care of the newborn with ease. The intention of a mother in-law to practice traditional newborn care is being influenced mostly by societal norms and their knowledge level. Most informal newborn care providers who were engaged in potential harmful practices like pre- lacteal feeds, immediate bathing of the newborn, discarding colostrum, not practicing EBF and application of substances on the umbilical cord endangered the health of the newborn. Majority of the literature reviewed were quantitative research studies regarding traditional newborn care practice, but few qualitative studies were found to explain traditional newborn care practices among mother in-laws in Ghana. 40 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES CHAPTER THREE METHODOLOGY This chapter consists of the detailed methods used in a systematic order to address the research questions. These includes the study design, settings of the study, target population, inclusion and exclusion criteria, sampling technique, data collection tool, data collection procedure, data management and analysis, methodological rigor and ethical considerations. 3.1. Study approach and Design Qualitative research approach was used for the study. Qualitative research is a valid and important mode of scientific inquiry that generates distinctive nursing knowledge and complements the knowledge produced by quantitative research. It is based on a subjective view that asserts the world known only through human beings’ perceptions (Creswell & Creswell, 2017; Polit & Beck, 2010). Therefore, participants varied perceptions on their beliefs and practices about traditional newborn care practices were gathered from the study to make a meaning. A research design is the specific procedures involved in the research process for addressing a research question (Polit & Beck, 2010). The research design employed in this study was exploratory descriptive design. Exploratory descriptive design is defined as the type of qualitative research design which is used when a new area is being investigated or when little is known about an area of interest. It may also be used to study the full nature of a phenomenon and other related factors (Polit & Beck, 2010). This design was considered because little is known or present understanding of the phenomena is inadequate and to understand the phenomena deeply 41 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES and in detail. This design enabled the use of open-ended question for participants to freely express themselves in their natural settings. 3.2. Study Setting North Gonja District is located in the western part of the Northern Region of Ghana. It lies within longitude 100 51’ and 200 581’ West and Latitude 800 321’ and 1000 21’ North. It shares boundaries with West Gonja and Wa East districts to the West, Tolon District to the East, Mamprugu-Moagduri and Kumbungu districts to the North and Central Gonja to the South. The district has a total land mass of about 4,845.5sq km, representing 6.9 percent of the total land size of the Northern Region. The 2010 PHC indicates that the District has a total population of 43,547 made up of 49.6 percent males and 50.4 percent females. Out of the total population, a majority of the population, i.e., 37,037 (85.1%) resides in the rural areas with the remaining 6,510 (14.9%) in the urban areas (Ghana Statistical Services, 2014). The district was carved out of the West Gonja District in 2012 following the 2010 Population and Housing Census as part of the efforts to deepen decentralization processes in the country. There are about sixty-eight communities in the district. These include Lingbinsi, Tari, Singa, Disah, Kagbal, Lukula, Wawato, Bawena, Mankarigu and Daboya as the major localities. The district is predominantly inhabited by the Gonja but there are also the Tampulma, Mamprusi, Hanga, Dagomba and Fulani. The people of the district celebrate a number of festivals, namely; Damba festival, Jintigi (Fire festival), Eidul-Fitri and Eidul-Adha. The main religious groups in the district are Islam, Traditional African Religion and Christianity (Ghana Statistical Services, 2014). 42 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES The district lies in the tropical continental western margin and characterized by a single rainfall pattern between April and October every year with Guinea Savannah as its natural vegetation cover. This is the Harmattan season (dry air) which occurs from late November to March. The mean annual rainfall is between 1000mm and 1500mm with the peak occurring from July to September. Temperature is fairly high with the annual mean temperature ranging from 27.4oC to 35oC depending on the season. The highest temperature is recorded in the dry season while the lowest is experienced during the Harmattan season. The major tree species are sheanut, dawadawa, baobab, acacia, neem and ebon (Ghana Statistical Services, 2014). The Total Fertility Rate for the District 5.3, the General Fertility Rate is 135.8 births per 1000 women aged 15-49 years. The Crude Birth Rate (CBR) is 31 per 1000 population. The crude death rate for the District is 6 per 1000. The death rate for males is highest for under five male children representing 15.7 deaths per 1000 population while for the females, the highest death rate of 12.5 deaths per 1000 population is also for under five female children (Ghana Statistical Services, 2014). The North Gonja District was chosen as the study settings because it has limited access to health care services for the communities under it, contributing to high neonatal morbidity and mortality rates. Also, there is no relevant literature about traditional newborn care practices among mothers in-law in this district. Therefore, the outcome of this study on the traditional newborn care practices will help the district health directorate to adjust in their newborn care interventions, it will also influence the government and other agencies to support the district in order to reduce newborn morbidity and mortality. 43 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 3.3. Target Population Participants were selected from the population of mother in-laws with the specific attributes of interest and relevance to the study in the Daboya Sub-district. 3.4. Inclusion Criteria Mother in-laws living with newborn babies age 6 months and below and their mothers who were residing in the Daboya community for the past one year or more and were willing to be participants in the study. 3.5. Exclusion Criteria Mother in-law who had some form of cognition impairment and mothers in-law who were not residents of the North Gonja District for the past one year were excluded from the study. This was because, they could not provide the needed information for the study. 3.6. Sampling Technique and sample size The process of intentionally selecting information rich individuals and sites with a wide range of variation on dimensions of interest to represent or form a subset of a total population to help in a detailed understanding of the phenomenon is known as purposive sampling (Creswell & Creswell, 2017; Polit & Beck, 2008). Purposive sample was used in this study because the researcher had the opportunity to explore mother in-laws with experiences regarding the research problem in order to enrich the data. Mother in-laws living with their newborn grandbabies 6 months and below were purposively recruited in the District after obtaining ethical clearance and permission to conduct the study. The researcher visited the Postnatal clinics every Thursday as it was a day set aside for PNC 44 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES services and on every Friday at the labour ward to work with the Nurses and Midwives in order to identify and establish rapport with newborn mothers with live babies. In all, about 20 newborn mothers living with their mother in-laws were identified at these units at the Daboya polyclinic and with the assistance of the nurses and midwives, participants contact phone numbers and home addresses were obtained for the purpose of tracing and recruiting participants (mothers in- law) at their homes. Six (6) participants out of the 20 participants declined to participate after explaining the purpose of the study and seeking their consent to be part of the study. Purposively, fourteen (14) mothers in-law (paternal grandmothers) were recruited as participants in order to obtain their broader views until there were no new information emerging from the subject under study. At this point, the data was said to be saturated (Polit & Beck, 2008). 3.7. Data Collection Tool The researcher used a self-developed semi-structured interview guide as the major tool for this study with an audio tape for recording. The researcher also used a codebook with protocols on data development, field diary for manual recording of non-verbal cues as well as electronic recording with two voice-recording devices, consent forms and instructional sheet. The semi- structured interview guide has section A and B. Section A elicited participants demographic characteristics and section B contained open-ended questions developed from the theoretical constructs and objectives of the study which constituted the main questions that elicited detailed information on traditional newborn care practices. The questions were categorized based on the objectives of the phenomenon under investigation. Participants were offered the opportunity to voice concerns that were not captured by the interview guide. The interview guide was pre-tested on four (4) mothers in-law at a community called Shinshena with similar characteristics to ensure that more clarity was in the research question and the results of these were later not added to the 45 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES main study findings. The findings of the piloted interview guide were reviewed by supervisors and peers to ascertain its dependability and credibility. 3.8. Data Collection Procedure The University of Ghana (UG) Institutional Review Board (IRB) of Noguchi Memorial Institute of Medical Research (NMIMR) reviewed and approved this study to be carried out. Permission was sought from the District Director of Ghana Health service, North Gonja, with an introductory letter from the School of Nursing and Midwifery, UG. The researcher sought permission from the management of Daboya health center and the head of the postnatal clinic with a permission letter from the office of the District Director for health services and community elders were identified as gatekeepers. The researcher was assisted by nurses and midwives at the labour ward and postnatal clinic of Daboya Polyclinic for the list of newborn mothers living with their mother in-laws. These lists and addresses were used to trace and recruit participants based on their understanding of the phenomenon until saturation was reached. The researcher prepared an information sheet to highlight anonymity and confidentiality of information, the research topic, purpose of the study and the objectives for the participants who met the inclusion criteria. The researcher explained to mother in-laws who could not read the information sheet in a language that they understand (Gonja). Phone contacts and home addresses of mothers in-law were taken to plan ahead the site, time and date for the interviews. An informed consent was given to those who were willing to participate to sign or thumb print highlighting on privacy and confidentiality before they were interviewed. Permission to record and write field notes during the interview was sought from participants. All interviews used interview guide and were recorded in language participants understands within 30-45 minutes. The researcher personal emotional turmoil in processing this information was discussed with the 46 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES supervisor during debriefing sessions after the pilot study and before the commencement of the main study in order to minimize biasness in the interview covered in main study. 3.9. Data Management and Analysis All interviewed audios were transcribed verbatim into typed text data using English language. The audio was played from a special equipment for easy navigations during the transcriptions process in a noise free environment. Hardcopies of field notes, consent forms, and text data and tape recorder were stored in a save locker with digital numerical combinations as keys in researcher’s office. Softcopies of the data were stored in files on the researcher’s computer encrypted with a password only known to the researcher and the supervisors. Both hardcopies and softcopies of data will be destroyed after a five (5) year period. Data was analyzed using thematic content analysis (Belotto, 2018). This type of analysis is to “capture and unify the nature or basis of the experiences into a meaningful whole” (Creswell & Creswell, 2017). In order to verify the accuracy of the data, the researcher listened to the audiotape comparing to the verbatim transcribed text using a computer. The transcript was then printed out for supervisor verification. Transcripts were read carefully to elicit codes for statements or concepts for regularities and patterns in the data. Sub-themes were developed from similar codes and then sub-themes with similar meanings were categorized into main themes. These themes were revised and refined with the narrative material until they were fit with the objectives of the study. Thematic content analysis brought meaning to the content narrative of mother in-laws experiences on traditional newborn care practices into prominent themes and patterns. 47 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 3.10. Methodological Rigor (Trustworthiness) As cited by Polit and Beck (2008), Lincoln and Guba (1985), promulgated standards for the trustworthiness of qualitative research that parallel the standards of reliability and validity in quantitative research. The main goal of rigour in qualitative research is to represent study participants’ experiences accurately. They suggested four (4) criteria for developing trustworthiness in qualitative research; credibility, dependability, confirmability, and transferability (Polit & Beck, 2008). Credibility: Refers to confidence in the truth and interpretations of data (Guba & Lincoln, 1994). Lincoln and Guba pointed out that credibility involves two aspects: first, carrying out the study in a way that enhances the believability of the findings, and second, taking steps to demonstrate credibility to external readers (Polit & Beck, 2008). To maintain the credibility of the research study, the interview guide was pre-tested to clarify and modify the questions. The researcher was assisted by the health care workers to recruit participants who met the criteria, the voice of participants was noted during transcription and member checking was conducted by tracing participants to confirm the accuracy of the transcribed data and the pattern of themes. The interview was a face-to-face encounter in order to help the researcher to do probing to elicit more in-depth information. The interview guide was pre-tested for clarity of research questions. Debriefing with peers and supervisors to ensure that accurate interviewing style and skills was also done. Transferability: Refers to the extent to which qualitative findings can be transferred to or have applicability in other settings or groups (Guba & Lincoln, 1994). The responsibility of the investigator is to provide sufficient descriptive data in the research report so that consumers can 48 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES evaluate the applicability of the data to other contexts (Polit & Beck, 2008). The researcher described the settings and the procedure involved during the study and selection of participants. Dependability: Refers to the stability (reliability) of data over time and over conditions. Credibility cannot be attained in the absence of dependability (Guba & Lincoln, 1994). Dependability focuses on whether the study findings when repeated with similar inquiry with similar participants at similar context will produce similar results (Polit & Beck, 2008). To ensure this in this study, experts reviewed adequate information about the methodological procedures using audit trails and code-recode strategy. Confirmability: Refers to objectivity, that is, the potential for congruence between two or more independent people about the data accuracy, relevance, or meaning (Guba & Lincoln, 1994). This criterion is concerned with establishing that the data represent the information participants provided, and that the interpretations of those data are not figments of the inquirer’s imagination (Polit & Beck, 2008). In order to achieve this, the findings must reflect the participants’ voice and the conditions of the inquiry, and not the biases, motivations, or perspectives of the researcher. All information that will potentially or actually influence the study was well documented. 3.11. Ethical Considerations An ethical clearance and approval to carry out this study was provided by Institutional Review Board (IRB) of Noguchi Memorial Institute for Medical Research (NMIMR) of the University of Ghana (UG). For the recruitment of participants for the study, permission was sought from the District Health Director of Ghana Health Services, Daboya, by presenting a copy of the approval letter and an introductory letter from the School of Nursing and Midwifery, UG. The researcher 49 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES adhered to research principles guiding human participants including respect for human dignity, anonymity, justice and beneficence (Polit & Beck, 2010). Respect for Human Dignity: A consent form containing all the information about the study was read and explained to participants who could not read in a language they understand and participants who could read were given the forms to read. Before giving voluntary agreement forms those who were willing to participate to sign or thumb print, it was explained to them by the researcher that they have the right to withdraw from the study at any point in time if they so wish. Participants were allowed to fix their own date and time and also appropriate venues for the interview process. Anonymity: Namelessness of participants was maintained and other personal information for identification were excluded during the interview process. Participants were assigned with false names (Pseudonyms) in order to conceal their identities. All interviews were carried out at appropriate venues to maintain privacy and confidentiality and participants were informed that participation was voluntarily. Justice: Participants were selected using the inclusion and exclusion criteria. Participants were not coerced to say things they were not willing to say, hence, they were treated equally with respect irrespective of their educational background, ages, religious affiliations. Beneficence: Participants were informed that findings will help the District Health Directorate of Ghana Health Services about how to strategize newborn care practices in the community. Also, the participants were informed of no direct benefits for them for participating in the study. 50 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES CHAPTER FOUR RESULTS/FINDINGS This chapter reports the findings of the study according to the objectives. The chapter presents the demographic characteristics, thematic content analysis structure, presentation of each theme and summary of the findings. 4.1. Demographic Characteristics of Participants All participants spoke Gonja language. The ages of the participants ranged between 45 and 75 years. Twelve (12) participants had no formal education whilst one (1) of them had primary school education. Out of the fourteen (14) participants, only one (1) participant was able to complete form three (3) level of education making her the participant with the highest educational level. Thirteen (13) out of the participants practiced Islam religion whilst one practiced Christian religion. On their marital status, nine (9) participants were married whilst five (5) of them were widows. Twelve (12) participants had single newborn grandbabies whilst two (2) of them had a pair of twins each. 4.2. Thematic content analysis structure Five (5) major themes were identified to be consistent with the TPB whilst two (2) major themes were not consistent with the TPB. All the major themes were corresponding to their sub-themes which were generated from the data. The emerged themes were identified from the data after several readings of the transcripts. Sorting and coding were done for all the seven (7) major themes. The major themes were classified as theoretical and emerged themes. This is illustrated on table 4.1 below: 51 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Table 4.1: Thematic content analysis structure Theme Sub-theme Code Theoretical Emerged Attitudes about TNC a. Positive appraisal ATT practices b. Negative appraisal c. Uncertainty about TNC Beliefs about TNC a. Perceptions SBN practices (subjective b. Spirituality norms, SN) c. Traditional norms Perceived a. High perceived PBC behavioural control control about TNC practices b. Low perceived control Intentions toward a. Plans before birth INT TNC practices b. Plans after birth c. Changes in plans after birth Behaviour about a. Use of herbal BHR TNC practices concoctions b. Bathing of newborn c. Feeding of newborn d. Maintaining body warmth of newborn Knowledge of mother in- a. Health information KDG laws on ENC on Essential Newborn Care (ENC) Authority of mother in- a. Decision about AUT laws over newborn care newborn care practices b. Societal pressure on newborn care 4.3. Attitudes of mother in-laws towards Traditional Newborn Care (TNC) practices In this study, attitudes of mother in-laws towards TNC practices were identified as the first major theme from the thematic content analysis of the data. Some mother in-laws appraised some practices to be good and whilst other practices were appraised to be bad. They developed positive attitudes towards the TNC practices that were appraised to be good and negative attitudes towards TNC practices appraised to be bad. It was realised that, they willingly engaged 52 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES in TNC practices they appraised to be positive for their grandchildren and disapproved those practices they appraised negatively. Positive appraisal, negative appraisal and uncertainty about TNC were the categories of attitudes reported. 4.3.1. Positive appraisal towards Traditional Newborn Care practices It was realised that, majority of the participants had a positive view towards Traditional Newborn Care practices. It was also worth noting that, some of them were confident to be engaged in the care of their newborn grandchildren because of their past experiences with newborn care. They thought their newborn grandchildren would grow up well and healthy because they have successfully taken care of other children in the past. The use of herbal concoction on the newborn babies was used to cure newborn ailments and also make them strong and healthy. Participant Serwah has to put it: hmmm!! the herbs are to make him strong and healthy, the shea butter on the wounds is to make the wound heal faster, drinking herbs is to stop abdominal pains and the enema or washing cherisheni is to reduce fever (Serwah). Yaa also had this to share: The herbs are to give them strength, the best pomade for a newborn is shea butter. Some of the herbal preparations I applied or gave them to drink are for spiritual purposes and others are to heal them (Yaa). Another participant stated that: erhmm!!! I have taken care of children before this one, and when I applied this to those children within some few days the wounds were gone. So, I realized it was good mixing the oil and the drugs on my grandchild’s wounds. …because I want the wounds to heal faster, because the drugs I just mentioned are things that heals wounds faster. And this will heal the wounds faster if I apply them (Foriwaah). 53 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Some of the participants were of the view that, immunization prevents childhood illnesses and death. They encouraged their daughter in-laws to send their newborn babies to healthcare center for these immunizations. This is how participants Adepa and Adwoa stated: I always remind and encourage my daughter in-law to send the baby for weighing at the clinic. The injections the give them has actually helped children from not suffering from gbankogu, chachabobi and ewasah tontong (Adepa). It is also good to send the baby to the hospital for injections, the TBA will tell us to send the baby to this village hospital. She said those injections will prevent the child from chacha boobi, Ewasa tong tong, and other sickness. I encourage my daughter in-law to always send the baby to for those injections, I love my grandchildren so much that I don’t want anything touching them (Adwoa). Majority of the participants also indicated that, giving newborn babies herbal concoction to drink or as enema helps in reducing their body temperatures whenever they have fever. They think it is the best way to minimize newborn fevers. This is what Yaa and Adom narrated: Sometimes when their bodies become warm, even if it is one of them who gets fever, I usually give all of them or I “wash them cherisheni” to reduce their temperatures (Yaa). I boil neem tree leaves for the baby to drink in order to treat the fever and malaria in him. Last week when this baby body became warm, it was those leaves I plugged outside and boiled and bath him and the temperature reduced (Adom). Participants with very positive attitude about TNC practices were of the view that, they will bathe their newborn babies immediately after delivery to remove the vernix caseosa and blood stains on their bodies. They think immediate bathing of the newborn after delivery was good and would prevent the baby from developing body odour. This is the view of Akose: The last time we had a child delivered at home by a Traditional Birth Attendant (TBA), I quickly bathed the child to remove those white substances and blood on the body (Akose). Owusuah also indicated that, bathing the baby immediately after delivery prevents the baby from developing body odour. 54 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Newborn babies come out with some white substances and blood on their bodies, if you do not remove them, the baby develops body odour. Immediate bathe would prevent that (Owusuah). 4.3.2. Negative appraisal towards Traditional Newborn Care practices Some participants appraised some of the TNC practices to be bad because of their previous experiences. They were not willing to be engaged in some of the TNC practices since that was not going to benefit their grandchildren. Some participants were not willing to give their newborn grandchildren tribal marks because of previous bad experiences. Others also had the view that, some of the practices were outmoded and as such, they resort to contemporary measures for the care of their newborn grandchildren. Some of the practices were also considered to be sinful by some participants. One of such participants had this to share: Some of the practices we have at home are not good for the babies. I have refused to give this baby tribal marks because, I don’t want to inflict too much pain on the baby. These tribal marks have denied a lot of people opportunities because, their tribe is easily identified (Adom). Konadu also stated that: I have changed my ways of practice. I would not be able to care for the baby with tribal marks very well. If I apply shea butter to the marks and umbilical cord, the child’s wound will delay in healing and this would be bad. This is why I did not allow the baby to be given the tribal marks (Konadu). On the other hand, Akose considered some of the practices associated with herbal preparations to be sinful. My sufferings of looking for many local medicines and sometimes some sinful acts before getting some herbs for the baby has come to a stop. Whenever the baby is not well, I quickly send someone to buy me the same drugs prescribed for us at the drugs store (Akose). 55 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Some participants who intended to practice some TNC for their newborn grandchildren resorted to seek assistance from contemporary practices because, they think some of the practices were outmoded. Akua claims: I have not bathed the baby any herbs nor given herbal concoction to drink. The herbs we bath these babies stains their skin and changes the skin colour to dark. Also, the way we give the herbs for newborn babies is not good, we force them to drink them which sometimes choke them. These are old practices and I would rather visit the clinic with them if any of them feels unwell (Akua). 4.3.3. Uncertainty about TNC Some participants were uncertain with their responses towards TNC practices. They were neither totally against the practice of TNC nor the practice of contemporary newborn care. They think practicing TNC and at the same time sending the newborns to the healthcare centers is good for the newborn baby. Foriwaah and Adwoa, had this to share: the TBA will ask daughter in-law to bring the items required to perform the rituals and when you gather and send them, she will perform the rituals for the nipples to open and she will come home with the herbs to be washing the breasts for more milk to flow. This doesn’t prevent us from sending him to the clinic, I will still encourage her to send the baby to the clinic for the healthcare workers to help in his care by checking his health status erhmm (Foriwaah). Although, my son always looks for some herbs which will be boiled and the concoction will be used to bath the baby. Sometimes it is the TBA who gives me some herbal concoctions and if it is a sickness that deserves to be sent to the hospital, then, I don’t hesitate to do so (Adwoa). Some participants also had some mixed feelings about TNC practices where they think giving newborn water was good to quench the baby’s thirst, but they also thought giving baby portions of same water used for bathing to be bad practice. Participant Ama, narrates as follows: hahahaha, my son, you know giving the baby water is good but you also know the water from the bath pot would become soapy and dirty. Sometimes her urine enters inside the water which would not be good for her to drink such water (Ama). 56 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 4.4. Beliefs of mother in-laws about Traditional Newborn Care (TNC) practices (SN) The second major theme that was identified in this study was mothers’ in-law beliefs about TNC practices. Majority of the participants responded to have a lot of beliefs about newborn care practices. These beliefs were classified into three (3) sub-themes including beliefs/ perceptions, spirituality and traditional norms. 4.4.1. Perceptions about newborn care Almost all the participants held some form of beliefs/ perceptions when it comes to the care they render to their newborn grandchildren. Majority of participants were with the belief that, colostrum should be expressed and discarded, this was considered to be “bad milk” and forbidden for the baby to suckle. Mother in-laws stated that, their newborn grandchildren were welcomed with ancestral feeds with the belief that, the babies dinned with their ancestors. Some participants believed in reciting some verses from the Qur’an to welcome the newborn. Majority of mothers in-law also held the belief that, newborn babies are not supposed to come outside the room until they are 40 days old. Some participants were with the belief that, the newborn’s hair was bad hair and needs to be shaved. Other participants also believed in tribal marks as symbols of identity whiles some participants considered bathing the newborn at night to be a taboo. Some participants have this to say about colostrum: The first breast milk from a mother is expelled and thrown away to prevent the baby from sucking them. it is a “bad milk” and the child must not be allowed to drink it (Akua). Milk that comes out first from a newborn mother are expelled and thrown away, this is believed to be bad milk (Konadu). 57 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Adepa and Asabea indicated that it is forbidden to allow the newborn baby to suckle the colostrum: It is forbidden for a newborn to drink the bad milk from the mother, so that milk was expelled and buried with the belief that more milk will flow for the baby to suck (Adepa). The bad milk from the mother’s breast is expelled away and it is forbidden for the child to take in such milk (Asabea). Adwoa had this to add: We belief it is a cursed milk and the child should not take it (Adwoa). Majority of mothers in-law indicated that, they welcomed newborn babies with feed from ancestors. They are with the belief that, newborn babies should eat with their ancestors before any other food and this prevents them from both physical or spiritual harm. Two participants indicated that: We also, belief that the newborn babies should eat with their ancestors, so last night when they were born their father brought the spiritual flour water mixed with shea butter oil and gave it to the newborns to drink (Akua). It is believed that, the first food to enter the baby’s mouth is the food from the ancestors which this baby didn’t get, the father had to sacrifice fowls to the ancestors for disobeying them (Abena). Some of the participants disclosed that, the ancestral feed is prepared during labour which is then blessed by the ancestors before the baby drinks it to signify a welcome by the ancestors. This is believed to confer both physical and spiritual protection for the baby. Ama and Owusuah claims that: Immediately a woman is in labour the husband goes out to get the milk from a cow before she delivers. And immediately the baby comes out and cleaned, she is sent before the oracles and incantations are done for our ancestors to bless the milk. I then drop some of the milk into the baby’s mouth. If it is a boy, it would be 3 drops and if a girl then 4 drops 58 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES to signify that the baby dinned with the ancestors first before any other food. This prevents the child from any kind of poison or spiritual harm (Ama). It is s special drink made up of water and millet flour with shea butter oil. Whenever, a woman is in labour this is prepared and poured as libation to the ancestors with the belief that the ancestors have blessed the drink and they are ready to dine with the newborn baby (Owusuah). Another participant who believed so much in her religion has this to say: In Islam, since the child is a male born, his father was called to come and recite some verses of the Quran into his ears as a form of blessing and a way of welcoming him into the Islamic religion. This is believed to make the child more pious and God fearing when he becomes an adult (Akose). All mothers in-law believed that, every newborn baby should not be allowed to come outside the room until the baby is 40-days old. They believed that the baby who is allowed to come outside the room before reaching the 40th day would be cursed by evil spirits and even if such a child comes out due to some urgent reasons, then the eyes should be covered to prevent the baby from seeing the sky. Some of the participants are also with the view that, rituals are performed on the 40th day before the baby is brought outside the room. Some participants have these to share: I still maintain the belief that until my grandchild is 40 days old, he would not come outside the room. My children went through this and nothing happened to them (Serwah). A newborn baby is not supposed to come outside the room until 40 days’ time with the belief that, the baby will be cursed…(Konadu). Another participant who had the notion that modern religion and civilization have changed a lot of olden beliefs, still believed that the newborn baby should not be brought outside the room until 40th days old. Insha Allah with religion and modernization, a lot of things have changed regarding newborn care. Although we still belief that, a new born baby is not supposed to be 59 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES brought out from the room until 40-days’ time. This is a belief that existed for long and my religion does not forbid that… (Akose). Adwoa stated that, in urgent situations the face of the baby should be covered before bringing the baby outside the room. The baby should not be out of the room, until she is 40 days old, even if she is to come out for some importance reasons, then her face must be covered with cloth to prevent her from watching the skies, it is forbidden at her age to watch the sky (Adwoa). Abena and Adom indicated that, rituals are performed on the baby on the 40th day before the baby is brought outside the room. This is believed to protect the newborn baby from evil harm. We have a belief that, the newborn is not supposed to come outside the room, especially during this harmattan weather. There is a period for the baby to be in the room, apart from the wind that is blowing now, it is a belief that, the newborn who is not up to 40 days old is not allowed to watch the skies, he might be possessed by the evil spirits. (Voice from one of the older children). Even when the baby gets to the 40th day, some rituals are performed and even after the 40th day when the baby is now allowed to come outside the room, he is sent back when it is getting dark (Abena). Newborns are not supposed to come out from the room until 40 days’ time and when they are about to come, there are some rituals performed before bringing them out to protect them from evils and their harm (Adom). Majority of participants are with the view that, the hair on the newborn should be shaved away. They have the belief that, the hair the baby came out with from the womb is considered to be “bad hair” and as such it is forbidden to allow such hair on the baby’s head. They resorted to shaving every newborn hair on their naming ceremony day. This is what two (2) participants had to say: The hair of the newborn is belief to be bad hair and this must be shaved on the naming day for new hair to grow (Konadu). 60 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Yaa with a pair of twins claims that: On the day of their (babies) naming ceremony, their penis was circumcised, their hairs shaved, tribal marks given and other rituals performed by a Wanzamu. This hair is seen as bad hair... (Yaa). Majority of the participants also believed that tribal marks signify tribal identity. They indicated that, a newborn baby should be given tribal marks on the body for easy identity as true and proud Gonja. Adom has this to say: The commonest belief we have as Gonjas is to give a newborn baby tribal marks on the face, arms and legs. And also, on the abdomen. These marks are to create identity on the individual or speaks to others who you are and where you are coming from (Adom). Some of the participants are with the notion that, the newborn baby should not be given bath at night. Therefore, a bath for a newborn baby born at night is delayed until the next morning. Participant Adepa had this to say: hmmm!!! Yes, I would have cleaned his body with hot water and towel whiles waiting to give him proper bathing in the morning with soap and sponge. We forbid bathing a newborn baby at night (Adepa). Another participant was with the belief that, a widow who has not gone through the widowhood rights is forbidden to touch the baby. They believe such a woman is not clean and may spiritually harm the baby. Konadu has this to say: We also belief that, a woman who has not performed the widowhood rites is not supposed to come closer to the newborn. This is believed that, such a woman is not clean and may harm the child spiritually (Konadu). 61 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 4.4.2. Spirituality about newborn care The second sub-theme identified under this theme was spirituality about TNC practices. Majority of mothers in-law were with the view that, spiritual consultations and ritual performances were considered when it came to the care of their newborn grandchildren. Some of the spiritual beliefs expressed have to do with going to elders for spiritual “breasts washing” to boost breast milk production for mother in-laws in situations where their daughter in-law dies leaving the newborn baby. Some participants indicated that, their newborn grandchildren were initiated to their family gods for their ancestors to provide protection for their newborn grandchildren from all kinds of spiritual harm. Others also believed in naming their newborns after their ancestors or shrines for spiritual protections. Majority of mothers in-laws stated that, in the event that the mother of the baby dies, they will go for rituals from spiritual elders on their breasts for BM to flow in order for their grandchildren to be breastfed. Adepa and Akua had this to say: Traditionally, if she (daughter in-law) dies leaving the baby, I would have to go for rituals from the elders for my breast to become full by “washing them” spiritually to allow milk to flow for him (baby) to breastfeed (Adepa). Akua, a grandmother of twin newborn babies indicated that: Traditionally, the elders are still there to “wash my breast” spiritually to allow milk to flow for the babies to be breastfed (Akua). On the other hand, another participant was also with the view that, a baby mother with her nipples blocked have to go for some specific rituals on her breasts from the spiritual elders for milk to flow for her baby to suck. Gonjas have some herbal preparations specifically for “washing the breast” in situations where the woman nipples are closed, they will perform those rituals for the breast to open for milk to flow for her child to suck (Asabea). 62 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Some participants believed that, the newborn baby should be initiated to the family gods for acceptance into the family. Some ancestors or shrines are sometimes named after these babies. Mansah has to say: A red cock was killed to appease the ancestors on the day of the naming ceremony and the blood from the cock was used on his forehead to signify acceptance from the ancestors (Mansah). Some participants shared their ordeals with their newborn grandchildren after birth. They believed that their grandchildren should be named after their family ancestors to stop them from crying unnecessarily. If the child is crying and wants a name, animals are killed to appease the ancestors for a name of an ancestor to be given to him. This child was named after his great grandfather, and that is why I call him my grandfather. Some children come from the shrines and they are named after those shrines (Konadu). She was named after her father’s aunty, before she stopped crying. This was after the consultation of the family priest when the baby was crying continuously after birth (Adwoa). Some participants were with the view that some ritual rites are performed to protect their grandchildren from evil harm. They tied charms on their wrists and waits for spiritual protections. Adwoa has this to say: …Again, in our tradition, I tied a thread with cowries on my grandchild hand and waist after some number of months after birth and my reason is to spiritually prevent any evil spirits from coming into contact with my grandchild (Adwoa). Abena indicated that, to spiritually protect her grandson from dying like her previous grandchild, a ritual was performed on this newborn by putting him in a woven basket and then placed it on the refuse dump with spiritual incantations. This boy was sent to the refuse dump the day they returned from Tamale, he was put in a local woven basket and kept on the refuse dump for a stranger to buy him with any 63 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES amount and he was bought by a Tampulma woman. She was the first person to come across the baby and then put money in the basket and removed him. This was done because the mother lost an earlier child before him with the belief that, this would spiritually end the death of future grandchildren including this current one. So, we call him Tampulma (Abena). 4.4.3. Traditional norms about newborn care Traditional norm was one of the beliefs that ran through almost all the participants’ responses. Majority of participants believed in practices that are common and accepted by all members of their family or the community at large in the care of their newborn babies. They would rather maintain what was left behind for them by their parents and elderly people in their family or community than to resort to contemporary measures of newborn care. Some participants had the belief that, practicing their family tradition makes them unique from different families. Mansah, Abena, and Akua had this to share: That was what they (her parents) met in the family and passed it on to me, so, I must also do same to maintain the norm not exactly what they will want me to do, but what is accepted in the family by all members is what is necessary (Mansah). Abena stated that: Actually, in this house, we believe in the “k’kpante”, so my son will look for them before the naming day so that the necessary rituals would be performed on them. This would be put in fire and would be used to touch the baby’s lips, if it is a male, three times and if it is a female 4 times. This is believed to help the newborns to be truthful and eloquent when they grow up. This has been the practice of our forefathers for a long time ago. We have our own way of caring for our newborn children and that is what we have always known and practices for years (Abena). Akua had narrated that: hmm !! actually this is what we all went through by our parents and that was applied to my children and now I am applying same to my grandchildren too. They will one day also apply it to their children too. These practices are family norms. When I got married to this family, I met my mother in-law who told me all what it takes to take care of a newborn and what not to do… (Akua). 64 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Another participant was with the view that, these traditional norms vary from family to family which makes each family unique based on what they believe and practice. Konadu had this to say: errmm!! With my parents and mother in-law, they have passed what was passed to them from their parents as well and this must continue to exist. This way it makes us different from other families… (Konadu). 4.5. Perceived behavioural control of mother in-laws about TNC practices Another major theme that was identified under the thematic analysis of data was the perceived behavioural control about Traditional newborn care practices. It was worth noting that, some of the participants were confident about performing TNC practices whilst others doubted their ability to perform TNC practices. Planned activities, availability of resources, thoughts and emotional patterns, skills and knowledge, and the zeal to carry out an activity had an influence on their confidence to perform a behaviour. Two sub-themes emerged; high perceived control and low perceived control. 4.5.1. High perceived control about newborn care practices It was realized that, some participants had confidence in performing TNC practices. Mother in- laws were with the view that, their skills and knowledge about carrying out TNC practices, their previous experiences about TNC practices, resources available for newborn care, intrinsic motivations about newborn care, and efforts expended in carrying out newborn care practices will motivate them to be engaged in newborn practices with ease. Some participants stated that, it was easy for them to carry out TNC practices due to their previous experiences. Adom and Abena had these to say: 65 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES I didn’t pay for the knowledge I had from my parents, friends and the TBAs and I didn’t travel to anywhere to acquire them, I was just here. Because I have practice that for years and it is now part of me, when I am practicing, I don’t see much difficult in doing it (Adom). Despite my daughter in-law having older children, she is still not perfect on how to care for newborn babies, but with my experience over the years it makes me feel like I can do it better… (Abena). A 50-year-old widow also indicated that, bathing the newborn was not something new for her to practice. The easiest thing in the care of my grandchild is the practice of bathing of my grandchild. It is something I have done over and over again, so is not a new thing to bath a newborn child. My son is always available to assist me with whatever I need in the care of his daughter (Adwoa). On the other hand, some of the participants indicated that, with their skills and knowledge about traditional newborn care practices, they find it easy to perform newborn care practices. Ama has this to share: I don’t need to pay for the services, I have the skills to do that. I am always available to assist my daughter in-law to care for the baby with my previous experiences. With this knowledge about child care, I can bath the baby with ease (Ama). Other participants were of the view that, resources to care for the newborn were available and as such it was easy for them to care for newborn. Foriwaah and Serwah had this to say: What makes it easy for me to practice is that, when I had most of the resources needed to care for the child, erhmm. With this, the baby gets proper care and it prevents him from many problems (Foriwaah). The materials I used in caring for the baby are readily available, my son provides whatever I request for the care of his son (Serwah). On the other hand, Abena stated that, it was less expensive in getting herbal concoctions for the baby. 66 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES hmmm!!! The herbal preparations we bath our newborn babies prevent them from certain illnesses and looking for those herbs are not costly or sometimes the father of the child goes to the bush himself to look for them without spending money…. (Abena). A 45-year-old married woman indicated that, her inward feelings for newborns makes her carry out newborn care practices with ease. hmmm!!! The passion I have for the newborn makes everything I do for him to be easy. It is my responsibility to perform those daily activities on him, so I cannot say because is difficult I would not perform them. I always see it to be easy for me to do (Mansah). 4.5.2. Low perceived control about newborn care Majority of the participants shared the view that, financial constraints made it difficult for them in carrying out newborn care practices. Three of the participants had this to say: Err!! The difficulty regarding the care of the newborn is about financial constraints. I am unable to acquire all what is needed in the care of my grandchild because there is no money. Those who are wealthy are able to take good care of their grandchildren (Akose). Asabea narrated that: erhmm!! Now adays money is everything, buying her bathing soap, dresses and shea butter oil are things we need money to buy. This becomes difficult to come by sometimes (Asabea). Another participant indicated that, she was poor and cannot afford newborn care items for the care of her grandchild. hmmm!! I need Baby new dresses, baby sandals, fire woods for heating water, soaps. A lot of things but money is the problem. We are poor, errhmmm!! (Foriwaah). Yaa, a grandmother of twin newborn babies indicated that, caring for twins consumes a lot of baby care items and also tedious. 67 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES …Also, at night we don’t sleep is either both or one of them wakes up and is crying. Bathing them consumes a lot of items unlike a single child, it needs more water, and soap. After bathing them I easily become tired (Yaa). Some participants narrated that, newborn care practices become difficult when the baby is sick. Adwoa and Adom had this to share: The difficulties I face is when my grandchild is sick. It is difficult to handle a sick newborn baby because she cannot talk (Adwoa). errhmm!!!he will be crying and can’t sleep. Sometimes, around the navel becomes so hard and warm. This becomes difficult to handle (Adom). Some participants perceived difficulties in caring for a newborn baby after the demise of their daughters’ in-law. Akose has this to say: This would be a difficult situation for a newborn to go through, now that he has to only depend on breast milk alone (Akose). Some of the participants stated that, injections on the babies from the healthcare facilities interfere with the way they care for their newborn grandchildren at home. Serwah claims that: The child becomes ill when they give him injections from the healthcare facility making it difficult to handle and care for him. He sometimes cries the whole day (Serwah). Adwoa narrates that: …Also, the injections given by the health workers usually interfere with the way I take care for my newborn baby (Adwoa). 4.6. Intentions of mother in-laws towards TNC practices Mother in-laws had different plans towards newborn care practices. Mother in-laws were of the view that, caring for the newborn was something they had done before. Those with strong 68 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES intentions about a particular TNC practices were likely to be engaged in such practices. Majority of participants had plans towards the care of their grandchildren before they were born. Some participants also planned to continue the execution of these plans after delivery whilst others added new plans after the birth of baby. Some participants had changes in plans after delivery. These plans were categorized into three sub-themes including, plans before the birth of baby, plans after the birth of baby and changes in plans after delivery of baby. 4.6.1. Plans before birth of baby Almost all the participants planned to organize newborn baby care items waiting for the arrival of their grandchildren. Some mother in-laws were with the notion that, in order to take proper care of their unborn grandchildren, they asked their daughters in-law to move from their husbands rooms and live with them in their rooms when the pregnancy was at term. Others too planned to organized food items to prepare their daughters in-law meals after delivery for enough breast milk production. Majority of participants stated that, they planned to personally bath their newborn babies when they are born. Some participants also planned to carry out their traditional beliefs on their newborn grandchildren when they are born. Serwah and Abena had this to say: I bought baby dresses and soaps to be used in bathing my grandchild. I gathered old clothes to be used as napkins and baby comforters. I was having shea nuts which I processed into shea butter to be used as the newborn baby pomade (Serwah). I bought baby dresses, sponge and soaps to be used in bathing my grandchild using the money my son gave me. I gathered old clothes and linens used for bread flour to be used as napkins. I bought a full calabash of shea butter oil that would be used on the baby. It is a norm of this community for every mother in-law to gather these items waiting for the delivery of their grandchild” (Abena). 69 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES A participant stated that, she requested for her daughter in-law to move into her room so that she could assist her during labour and also take care of the baby after delivery. Two of such participants claimed: …I told my son to let his wife move to my room when the pregnancy was around 8th month so that at any point, she is in labour I can be of assistance and when she is to deliver then it will just be easy in my room (Mansah). Actually, my daughter in-law was staying in my son’s room until her pregnancy was around 7 months, then I requested she should move and stay with me in my room. I actually want to be the person to bath and care for my grandchild according to our traditions (Serwah). Some participants gathered food items awaiting to prepare nutritious meals for their daughter in- laws to boost breast milk production for their newborn babies to suckle: I worked hard to gather money ahead and also gathered ingredients for soup and other food items as it is a norm in this community for every mother in-law expecting a grandchild. My daughter in-law should eat well to be able to breastfeed my grandchild. I was comfortable when she was in labour because I knew I was prepared to take care of both child and mother (Asabea). Another participant also had this to say: …What my daughter in-law will eat after birth for enough breastmilk to be produced was important to me. I gathered food items for soup including groundnut paste, “aniiri”, maize flour, and other ingredients…(Adwoa). Another participant intends to personally be in the position of bathing her newborn grandchild when the baby is born. My plan was that, I was praying for her (daughter in-law) to deliver successfully so that I will be able to take care of him to become successful one day. It was my plan to be bathing the baby and also make sure he is always clean (Adom). 70 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Adepa and Abena planned to continue practicing their traditional norms on their yet-to-be born grandchildren. I saw the positive results on my own children when my mother in-law and sister in-law did for my children and as such I must continue with those practices for my children- childrens’ (Adepa). All of us went through what our parents practiced on newborn care, so shall we also do same to our children and grandchildren. We can’t abandon those practices and I have not thought of doing so (Abena). 4.6.2. Plans after birth of baby Majority of mothers in-law made up their minds that, it was their responsibilities to take care of their grandchildren immediately they are born. Some participants planned to assist and coach their daughter in-laws on newborn care practices. Some mother in-laws continued to care for the newborns as planned before the babies were born. Some participants also planned of caring for their newborns circumcised penis and or umbilical cords. Adepa and Akose indicated that: The practices I rendered over the years make me think I can care for the baby better. Besides it is my responsibility to do that as the grandmother. I told you he is my husband and I have to give him my best (laughs) (Adepa). err!! I am the mother of his father, whether I have the capabilities or not I just have to take care of him (newborn baby). Is that not true? I have taken care of many children before him and I would take care of him as well (Akose). Some participants planned to teach their daughters in-law who just had their first babies on newborn care practices. This is what Akua stated: …I will also teach my daughter in-law on how to breastfeed them and also how to pick and handle a newborn baby since this is her first time of delivery, she has no experience. 71 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES She is still struggling on how to pick them for breastfeeding, I have to coach her to do it well... (Akua). On the other hand, Adepa had this say: It was in my plans to allow my daughter in-law to start bathing the baby herself with little coaching after the baby’s 40th day. This is not her first of delivery, she has given birth to two children before this one. My plan is to assist to handle the baby whenever my daughter in-law is busy performing the house chores (Adepa). Another participant planned not to allow her daughter in-law to start caring for the newborn baby until wounds on the penis and umbilical cord are completely healed. I also planned to take care of the umbilical cord and the circumcised penis until the wounds are healed before I would allow my daughter in-law to start bathing him (Serwah). 4.6.3. Change of plans after birth of baby The statements of some of the mother in-laws revealed that, there were changes in some of their initial plans made. Majority of participants were with view that, their plans were not changed, they continued to practice with the plans they made before the delivery of their grandchildren. However, it was noted that, those with twins had their initial plans changed because they had planned to care for a single baby. However, participants indicated that their plans did not change and had these to share: The plan has not changed, since I am using the items on her as that was its purpose. All what I have to add is the dresses as she increases in size, some of the dresses would not fit her again (Adwoa). 72 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Foriwaah on her part disclosed that: Hmmm!! The planned has not changed because she didn’t go through operation or any difficult, so therefore the plan I had didn’t change. Although she didn’t give birth to the baby here, after her return we are using them… (Foriwaah) On the other hand, some of the participants with twins indicated that their plans towards the care of their newborn babies changed after the babies were born. This is how two of the mothers in- law with twins claimed: It has changed because I had to buy more and gather more items for the care of two babies instead of the initial one. This was a serious situation because we were financially down due to the money we spent at the hospital in Tamale. We just had to sell some of our harvested farm produce even lower prices than the market price in order to get money to support (Yaa). It has changed, because I was expecting single child but I was surprised they came out to be two. I had to add more items to what I already gathered for the single child (Akua). 4.7. Behaviour of mother in-laws on TNC practices Behaviour of mother in-laws towards TNC practices was identified as the last main theme from the TPB using thematic content analysis of the data. Majority of mothers in-law demonstrated actual control over their behaviours in some aspects of newborn care practices. These practices compared to standards of newborn care may either be of beneficial or harmful to the newborn baby. These behaviours were either influenced by mother in-laws perceptions or plans about newborn care or both their perceptions and plans about the behavioural performances. The identified behaviours were categorized into four (4) sub-themes; use of herbal concoctions on newborn babies, bathing of newborn babies, feeding of newborn babies and maintaining warmth of newborn babies. 73 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 4.7.1. Use of herbal concoctions on newborn baby Almost all the participants applied or gave some herbal concoction to their newborn grandchildren. Some participants applied shea butter mixed with other substances on their newborn umbilical cords, on their newborns circumcised penis, and tribal marks. Others also gave their newborns herbal preparations to drink whilst some participants bathed their newborns with herbal concoctions. Some participants also applied herbal concoctions topically on their newborns bodies and others too gave some herbal concoctions to their newborns as enema. Some participants stated that, they mixed shea butter oil with chloramphenicol capsules which they applied on the umbilical cord and tribal marks of their newborns. They also applied different herbs on other parts of the newborn baby. hmm!!! like I said, I apply shea butter mixed with “tuupaya fuful” using a fowl feather on their umbilical cords, their bodies are rubbed with shea butter oil, black herbal medicine is applied on the marks around their waists and writs. I also contacted the TBA for “Efru” herbs, it will be ready in two-days’ time, and when it comes I will apply it on their fontanelle…(Yaa). Applying shea butter mix with “tuupaya fuful” is good in healing the umbilical cord and the tribal marks. After shaving her head, I applied black herbal preparations on her head (fontanelle), as you can see it. This is to make that portion strong. We have started bathing her herbs that would prevent her from convulsions, make her strong and spiritually protect her from evil doers. Tribal marks were given on the baby’s waist and I applied black medicine on the marks (Konadu). Some participants also used tailor oil mixed with Akumadada, which is applied on the umbilical cord and tribal marks of their newborn grandchildren. Abena had this to share: errmm!! I put shea butter mixed with “akumadada” on the umbilical cord, burnt herbal preparation is mixed with shea butter and is used on the fontanelle. I gave the baby some herbal medicine some few days ago when she was having stomach pains, when the body temperature was also hot, I gave her enema…. (Abena). 74 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES On the other hand, a devoted Muslim participant stated that, she applied tailor oil mixed with amoxycillin on the circumcised penis and umbilical cord. She also gave concoctions from written Islamic verses for the baby to drink. I apply a mixture of tailor oil and amoxycillin on the circumcised penis and umbilical cord. I also gave him “walga” from a mallam to drink. I applied local black powder on the wounds around the abdomen. I also rub the body with shea butter after bathing. I am yet to start bathing him herbs that are Islamically prepared. (Akose). Owusuah narrated that, apart from applying herbal concoctions on the body and bathing the baby with herbs, her grandchild was not given any herbal concoction to drink. I have to clean the umbilical cord and the circumcised penis and then I apply shea butter mixed with tailor oil and akumadada, the body is rubbed with shea butter, black medicine is applied on the head to heal the fontanelle. I have not given herbs to the baby to drink but I only bathed him with herbs twice. I wore him “chakanto”, and tied cowries on his waist and wrist…(Owusuah). 4.7.2. Cleanliness of newborn baby Majority of participants were concerned about the cleanliness of their newborn grandchildren. Most participants bathed their grandchildren immediately after delivery whilst those who had their grandchildren delivered at night or at the health facilities delayed in bathing them, however they were cleaned with wet towels. Some mother in-laws encouraged handwashing before picking up their newborn babies. Majority of mothers in-law bathed their babies in the morning, afternoon and evening every day. They also cleaned the umbilical cord and circumcised penis of their newborn grandchildren during bathing. Three of such participants have these to share: Daily I do bath them 3 times, that is morning, afternoon, and evening. During bathing I fold their arms and legs together and direct the buttocks into the basin and use the calash to fetch the warm water to “chuure” them. I clean their circumcised penis and marks (Yaa). 75 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Mansah indicated that: ...During bathing I make sure I clean the penis and umbilical cord by washing it with water. I hold his hands and legs together like this (demonstrating the act) and send him closer to the water and then uses the small container to be fetching and pouring the water on the body… (Mansah). Akose also narrated that: So, the care I provide for my grandchild is daily bathing and cleaning him whenever he soils his clothing and linens. The bathing continues daily in the morning, afternoon and evening (Akose). Owusuah claims that, she baths her grandchild inside the room. During bathing, she massages and stretches the newborn to become flexible at his joints. On daily basis I fetch water into the earthen pot and bath him inside the room. During the bathing, I massage him with shea butter oil, stretches his arms and legs so that tomorrow his hands can reach his back to wash it, I also “chelchelmu” with the water at the buttocks and back (Owusuah). Majority of participants who had their newborns delivered at home expressed their views that, it took them short time to start caring (bathing) for their newborn babies immediately after they were born. Adwoa and Adom have these to say: It didn’t take much time before I started caring for the baby. Immediately after he was born, water was put on fire to bath and clean him and then I kept him down. At night I bathed him, the next day in the morning, afternoon and evening I bathed him (Adwoa). The time it took me to start caring for the baby was not all that long, because she delivered in this room by assistance of the TBA and I received the baby after she cut the umbilical cord and tied it with a thread. I quickly covered him with a clean cloth and put in down somewhere comfortable. I then prepared bathing water to wash his body. So, it did not take much time (Adom). 76 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Another participant with twins indicated that, before she picks up her grandchildren for bathing, she has to wash her hands thoroughly to be clean. Akua narrate that: Before I pick up the children for bathing, I have to wash my hands with soap and water to make my hands clean, the skin of the children is soft and care must be taken. I start bathing them from the head and face first and then the rest of their bodies… (Akua). 4.7.3. Feeding of newborn baby Majority of the participants indicated that, they gave pre-lacteal feeds to their newborn grandchildren before initiating breast milk. Some of the participants gave their newborns millet flour with water mixed with shea butter oil or cow milk whilst others gave only cow milk to their newborns. Some of the participants also stated that, they gave delicious meals for their daughters in-law to increase in their Breast milk (Smittenaar et al.) production. Majority of participants also expressed and discarded the first BM (colostrum) from their daughter in-laws’ breasts. Some of the participants encouraged their daughter in-laws to wash their breast before breast feeding their newborn babies. Some of the mother in-laws gave their grandchildren water from the same source of water used in bathing their newborn grandchildren to drink during bathing. Mansah, Owusuah and Ama had this to share: This boy was given that drink before he started breastfeeding. It is believed that the intestines of the newborn baby are coiled and in order to stretch them, he was given fluid drained from millet mixed with cowmilk to drink (Mansah). Owusuah, a grandmother of a 4-month-old baby stated that: …I then gave him the spiritual drink from our ancestors as the welcome drink with three drops into his mouth before he starts breast feeding…I gave him millet flour water to drink immediately he was born, I just finished giving him “moli kooko” before you came in. I also give him the drugs they gave us from the hospital (Owusuah). 77 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Some of the participants indicated that she gave cow milk to her newborn grandchild to drink when her daughter’s in-law breastmilk was not flowing. Ama had this to say: When this baby was born here, I quickly attended to her (baby) by bathing her to remove the blood and dirt on her and she was hungry, so I gave her cow milk since her mother’s breast milk was still not flowing (Ama). Another mother in-law stated that, she gives her grandchild water to drink from the same source of water used for bathing the newborn baby. Serwah narrates that: I have a small calabash with a small hole in the middle which I use to fetch the water from the “clay pot” to bath him. During bathing I drop some of the water into his mouth through that hole from the calabash (Serwah). As mothers’ in-law are making sure that their grandchildren have the best care, they also supported their daughter’s in-law in relation to breastmilk production. They cooked delicious meals for their daughter in-laws to eat for more breast milk to be produced for their grandchildren to suck. Foriwaah and Asabea narrates that: I boil “pampa” using dry millet or maize flour, I add shea butter oil and “kanwa” and she drinks, this increases milk production in her breasts. I then also stir TZ for her to eat to increase her breast milk erhmm!! This are little things I do to support (Foriwaah). …I also make sure that my daughter in-law gets proper food to eat, food that will help in the production of breastmilk like groundnut soup and hot TZ (Asabea). Majority of the participants indicated that, they massaged, expressed and discarded colostrum from their daughter in-laws breasts to avoid their newborn grandchildren from sucking it. Ama stated that: Every woman breast swells after delivery and not opened at the first day of delivery. On that day I had to massage her breasts (daughter in-law) with shea butter and expressed the bad milk into a calabash and discard (Ama). 78 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Adwoa also narrates that: I massaged my daughter in-law’s breast to express and discard that “bad milk” (Adwoa). 4.7.4. Maintaining body warmth of newborn Maintaining body warmth of the newborn was one of the major practices carried out by some of the participants. Some of the participants covered their newborn grandchildren with clean clothes immediately after delivery whilst others upon covering their grandchildren still had to heat their rooms with fire in a coal-pot during the harmattan period at night. Yaa, Ama and Akua had these to share: I covered them with clean clothes to prevent them from cold, the harmattan here is severe because of the river. I heat the room by putting fire in a coal-pot with charcoal for the whole night. I don’t bath at down, I wait when the sun rises, because of their nature and the weather, harmattan (Yaa). Ama indicated that: The mother gave birth at home and immediately the baby came out, she was handed over to me by the Traditional Birth Attendant (TBA) after cutting her cord. I wrapped her with clothes and put her down. I quickly prepared warm water to bath her in order to remove the white dirt and blood stains from her body…(Ama). Akua on her part narrates that: Before we left the clinic last night, I wrapped them in clean clothes, my sister picked one baby and I also picked one whiles my daughter in-law was carried by her husband on a motor bike to the house (Akua). 4.8. Knowledge of mother in-laws on Essential Newborn Care (ENC) practices Knowledge about ENC practices among majority of mothers in-law was the first emerged theme to be identified, it was not consistent with the theoretical model used for the study. Majority of 79 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES the participants had varied information from different sources about newborn care. Majority of the participants stated that, they had newborn information from informal referent others (TBAs, mothers in-laws, sister in-laws and other family members) whilst some of the participants had received newborn information from Nurses and Midwives. Health information on ENC practices emerged as a sub-theme. 4.8.1. Health information on Essential Newborn Care (ENC) practices Majority of mothers in-law indicated that, they received traditional newborn information from their family members and TBAs. Some participants had misconceptions about ENC practices and as such they were not willing to be engaged in those practices. However, some participants could remember some optimal newborn care practices they were taught by the Nurses/ Midwives at the healthcare center or at home during home-visiting. Some participants found it difficult not to practice their traditional norms that they were taught by family members, TBAs and friends. Majority of women indicated that they had their newborn information from informal referent others in the community. Adwoa claims that: I haven’t received any teachings from them (nurses/midwives) on how to care for my grandchild. I care for my grandchild according to the way my mother and mother in-law taught me. The TBA is currently assisting me with some ideas. (Adwoa). Abena had this to say: Apart from the TBA and other elders in this community, no other person tells me about how to care for the newborn grandchild. Here is far from the clinic, though the nurses do come to our homes sometimes but they don’t discuss on how we should care for the babies. I cannot remember the last time I saw any of them on this compound (Abena). Some participants had misconceptions about some ENC practices. Ama narrates that: Women who go to deliver at the hospitals complains that the doctors usually use instruments to cut them and also, they ask them to give the bad breastmilk to their babies 80 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES They usually come home with problems either with the baby or the mother. So, do you think I would allow even my enemy to go to this place to deliver? God forbid!! (Ama). Akua, a grandmother of twin babies had this to say: The babies are not up to 6 months, the nurses are saying that I shouldn’t give them water and food. It will be difficult for me to take care of newborn babies for 6 months without water, they would be starved and may die (Akua). On the other hand, some of the participants were able to memorize some of the information given to them by Nurses/midwives about ENC practices. Foriwaah stated that: At the clinic they taught us how to care for my newborn grandbaby, they told us to practice exclusive breastfeeding for 6 months, we shouldn’t give water to baby less than 6 months. After that period, we can start giving the baby water and “moli kooko”. They taught me all these things whenever I visited the clinic. They also taught us on how to assist my daughter in-law on how to handle the baby during breast feeding. They taught all these, and I usually follow that (Foriwaah). Another participant indicated that, despite the information given by the nurses/midwives at the healthcare facility on the care of her grandchild, she cannot adhere to those protocols at the expense of her traditional newborn care practices. Mansah stated that: hmmm!!! They are saying I shouldn’t give food and water until 6 months time, I shouldn’t give tribal marks, I shouldn’t give the newborn herbal medicines. They are saying we should always bath them with cold water whenever they have fever and always cover them with cloths, and we should bring them for weighing. I have not been practicing all what they told me, I can’t abandon my traditions and take a white man’s own (Mansah). 4.9. Authority of mother in-laws over newborn care practices Another emerged theme that was identified was authority of mother in-laws over newborn care. Majority of mothers in-law demonstrated authority over newborn care choices. They exhibited power as to what happens to their grandchildren even against the wish of their sons and daughter 81 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES in-laws about newborn care practices. This authority was exercised in two categories; decision about newborn care and societal pressure on newborn care. 4.9.1. Decision about newborn care Majority of responses from the participants revealed that, they were the main decision makers when it comes to the care rendered to their newborn grandchildren. Newborn care choices were decided by mother in-laws, even when it was against the wish of their daughter in-laws. Two of such participants had this to say: My daughter in-law one day wanted to send the boy to the health facility, that her friend advised her to do that. I became annoyed and warned her never to attempt that or else the baby will be cursed by the evil spirits (Mansah). I can remember the day this baby was born and I wanted to give her the ‘milk from our ancestors’ before she can start taking her breast milk from her mother and my daughter in-law tried to stop, I shouted on her and told her that even her husband, my son cannot stop me from that (Ama). 4.9.2. Societal pressure on newborn care Majority of participants indicated that, their ways of practicing newborn care was influenced by the informal referent others. Some also stated that, it was the healthcare providers who influenced their ways of newborn care. Some participants were of the views that, they would be insulted by people in the society if they fail to practice the traditional newborn care. Abena and Akose had this to say: …I was being influenced by others and I observed how other women cared for their babies especially, my mother in-law who used to bath children. It was my mother in-law who coached me how to care for a newborn baby and that is exactly why I am doing this to my daughter in-law as well (Abena). 82 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES …this boy was not given some of the marks because the “female doctors” at the health facility are against it. They sometimes come into our homes to tell us the things we should do and they usually condemn giving tribal marks. We are gradually losing our identities as Gonjas. Well, they have been to school and they know better than we the black heads (she laughs) … (Akose). On the other hand, some of the participants stated that, the healthcare providers influenced some of their ways of caring for their grandchildren. Adom narrated that: Those days newborn babies were given warm water mixed with shea butter oil to drink before breastfeeding to open the intestines, but now the health care workers said we shouldn’t even give them water for a period, so this child was not given anything (Adom). Some mother in-laws indicated that, they would be insulted by people in the community if they fail to practice their traditional newborn care. Ama had this to say: It is a tradition for every mother in-law or grandmother to care for her grandchild. The society would insult you if you fail to do so. My age mates would insult me of not being able to care for my blood grandchild. My ancestors would also not be happy with me (Ama). 4.10. Summary of findings The attitudes of participants towards TNC practices were varied. It appeared that, some mother in-laws appraised some practices to be good whilst other practices to be bad. Others were uncertain of some of the practices either to be good or bad. Majority of participants were willing to be engaged in TNC practices they appraised to be positive for their grandchildren and disapproved those practices they appraised negatively. Participants who were uncertain about some of the TNC practices were in a state of dilemma as to how to render care for their grandchildren. Traditionally, almost all the participants held some form of beliefs when it comes to the care they render to their newborn grandchildren at home. Some of the spiritual beliefs expressed have to 83 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES do with going to elders for spiritual “breasts washing” to boost breast milk production for mother in-laws in situations where their daughter in-law dies leaving the newborn baby. Majority of participants believed in traditional practices that are common and accepted by all members of their family or the community at large in the care of their newborn babies. It was worth noting that, some of the participants were confident about performing TNC practices whilst others doubted their ability to perform TNC practices. Majority of the participants shared the view that, financial constraints made it difficult for them in carrying out newborn care practices whilst others were of the views that, their skills and knowledge about carrying out TNC practices, and their previous experiences about TNC practices influenced them to practice TNC with ease. Furthermore, the study revealed that, majority of participants had plans towards the care of their grandchildren before they were born. Some participants also continued to execute these plans after delivery whilst others added new plans after the birth of the baby. It was noted that, those with twins had their initial plans changed because they had planned to care for a single baby. Behaviour of participants towards newborn care was another remarkable finding of the study. Majority of mothers in-law demonstrated actual control over their behaviours in some aspects of newborn care practices. These practices as compared to essential newborn care practices may either be of beneficial or harmful to the newborn baby. Some of the identified behaviours included feeding the newborn with herbal concoctions, bathing the newborn baby with herbal concoctions, feeding and maintaining warmth of the newborn baby. Majority of mothers in-law indicated that, they received traditional newborn information from their family members and TBAs. They would rather maintain what was left behind for them by 84 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES their parents and elderly people in their family or community than to resort to contemporary measures of newborn care. Some participants had misconceptions about ENC practices and as such they were not willing to be engaged in those practices. Generally, participants were having inadequate knowledge on essential newborn care practices due to inadequate health education rendered by Nurses/Midwives and other factors aforementioned. When it came to authority of mother in-laws, they were the sole decision makers for newborn care choices, even when it was against the wish of their daughters in-laws and sons. Pressure from the society and significant referent others influenced participants decision in rendering care for their grandchildren. Most participants were of the view that, they would be insulted by people in the society if they fail to enforce their traditional newborn care practices. 85 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES CHAPTER 5 DISCUSSION OF FINDINGS 5.1. Demographic characteristics of participants The findings of the current study suggests that, all the women who participated in the study were all Gonjas. It was not surprising to realize that, they were able to understand and speak the Gonja language fluently. According to Ghana Statistical Services (2014), Gonjas are the majority of tribe among the other tribes in the North Gonja District. The ages of participants were between 45-75 years. Women within this age range are expected by society to be in their menopausal period and seen as elderly women in society. Also, the current study revealed that majority (12) of mother in-laws had no formal education. Similarly, studies conducted in Ethiopia among women suggested that majority of the participants had no formal education (Alemu & Eshete, 2020; Hill et al., 2020). However, previous studies presented contrary view (Agudile et al., 2020; Liu et al., 2013; Odom et al., 2014) where majority of women gained higher educational level. It is more likely for the mother in-laws to be engaged in TNC practices since they cannot appreciate ENC practices due to their low education level. Therefore, girl-child education should be encouraged and supported by all stakeholders in the community. Furthermore, findings from this current study also revealed that, majority (13) of the participants practiced Islam religion while one of the participants was a Christian. However, almost all the participants from both Islamic and Christian religions were engaged in Traditional religious practices. It maybe arguably right to state that traditional religion had much influence on mothers in-laws choice of newborn care practices. 86 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Interestingly, majority (9) of the participants were married whiles five (5) of them were widows and they were all living in their marital homes with their daughters in-law as reported in previous literature (Falnes et al., 2011). Mother in-laws living in the same homes with their daughter in- laws makes it easier for them to take proper care of their newborn grandchildren. In northern Ghana, paternal family claims ownership of every grandchild and as such daughter in-laws after birth are supposed to stay in the same house with their mother in-laws for some period. However, in situations where the paternal grandmother is not available, the mother and her newborn move to stay with baby’s maternal grandmother for some period. Again, findings from this current study uncovered that, some of the participants were having a pair of twin newborn grandbabies each. 5.2. Attitudes of mother in-laws towards Traditional Newborn Care (TNC) practices In this current study, majority of mothers in-law appraised some practices to be good whilst other practices were appraised to be bad. They developed positive attitudes towards the TNC practices that were appraised to be good whilst those who also perceived these practices to be bad developed negative attitudes towards TNC practices. Also, mother in-laws who believed in both contemporary newborn practices and traditional newborn care practices demonstrated uncertainty towards newborn care practices. Positive appraisal, negative appraisal and uncertainty about TNC were the categories of attitudes reported. Obviously, these categories of mother in-law’s attitudes towards TNC practices were found to vary and no literature has been found to have categorize attitude into these forms. Findings from this current study revealed that, majority of mothers in-law supported the idea of immediate bathing of their newborn grandbabies. The mothers in-law indicated that, vernix and 87 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES blood stains on the newborn babies are washed off immediately after delivery to prevent them from developing body odour and studies conducted in Nigeria (Adejuyigbe et al., 2015; Adelaja, 2011) and in Bangladesh (Hunter et al., 2014) revealed similar practices. In contrast, mothers in- law and care providers considered it normal to cover newborn babies immediately after birth and postponed first bath in Tanzania (Dhingra et al., 2014; Shamba et al., 2014). In addition, Hill et al. (2020) discovered in their study that, it was culturally accepted by all grandmothers to practice delayed bathing of their newborn grandchildren. In Northern Ghana, elderly women (mothers in-law) are seen as the sole care takers of newborn babies especially bathing of newborn babies. Immediate bathing of the newborn baby may predispose the newborn baby to hypothermia and eventually death. For this reason, mother in-laws and mothers should be discouraged from giving immediate bathes to their newborn grandchildren in order to keep them warm. The duration to start bathing the newborn baby after birth and the benefits of delayed bathing as recommended by the World Health Organization (WHO) should be explained into details to the understanding of informal care providers by the primary healthcare providers. The current study revealed that, some mothers in-law appraised shea butter oil to be the best pomade to be applied on the body of their newborn babies after bathing them as similarly reported in a previous study (Jenifer & Benjamin, 2019). The assertion of these mother in-laws can be attributed to the fact that, years past, shea butter oil was the only oil available as pomade in the northern territory of Ghana because of the abundance of shea trees in the area and also because of the dry weather condition. Applying shea butter oil on the body of the newborn baby is not harmful to the health of the baby as it smoothens the skin and prevent it from drying especially during the harmattan season. However, applying the oil plenty on the body can be a source of trapping dirt and microorganisms on the skin of the newborn which can lead to 88 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES infections. It is therefore important to encourage mother in-laws and mothers to practice moderate application of the shea butter oil on their newborn babies bodies. In the Ghanaian society, caring and treating of minor ailments of the newborn baby is held in high esteem by elderly women and is considered as their responsibility. Therefore, many elderly women are involved in actions that seek to address the newborn ill-health situations. Findings in this current study revealed that, majority of the mother in-laws supported the use and application of substances like herbal bathes, herbal enema (Cherisheni), applying shea butter oil on umbilical cord and tribal marks and giving herbal drinks to treat minor ailments of their newborn grandchildren. These practices are consistent with findings of studies in both Africa (Degefie et al., 2014; Dhingra et al., 2014; Kavle et al., 2014) and abroad (Angelo et al., 2020). In contrast, studies from both Africa and abroad argued that, maternal grandmothers who had positive attitude for breastfeeding practices were not willing to give any herbal concoction to their newborn grandbabies to drink (Agudile et al., 2020; Mueffelmann et al., 2015). The love grandmothers have for their grandchildren are undisputed, and as such they do everything in their capacity to see these children growing well and healthy. However, giving the newborn baby herbal medicines interfere with exclusive breastfeeding and are also detrimental to the health of the newborn baby. These herbal concoctions are not scientifically proven to cure those illnesses as claimed and as such it is imperative to educate grandmothers on the need to seek for medical care for their newborn grandbabies. Furthermore, mother in-laws argued that, they encouraged their daughter in-laws to send their newborn grandbabies to postnatal clinics for immunizations to prevent them from Measles (Gbankogu), Poliomyelitis (Chachabobi) and Whooping cough (Ewasah tontong) childhood illnesses. Similarly, studies conducted in Asia by Vinu et al. (2014), in Erode and Tiwari et al. 89 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES (2014), in Western Nepal, revealed that majority of mothers in-law caring for newborns had positive attitude in seeking for medical postnatal and neonatal care for their newborns despite the influence of traditional beliefs that existed in the area. However, the findings from this current study is inconsistent with findings of studies conducted in Northern Ghana (Degefie et al., 2014; Moyer et al., 2012). The ideal for every newborn care is that, the baby should be immunized against all the childhood preventable diseases as scheduled per the Expanded Program of Immunization (EPI). One of the activities put in place to achieve the Sustainable Development Goals (SDGs) in 2030 is that, every child should be immunized against all childhood preventable diseases. It is therefore, imperative to encourage mother in-laws and mothers to send their newborn babies for routine immunizations to prevent them from these childhood diseases. Another cardinal finding from this current study is that, some mothers in-law evaluated certain TNC to be outdated practices. The mother in-laws disclosed that, the practice of giving tribal marks were outmoded and was perceived to be bad practice. For this reason, the mother in-laws denied the Wanzamu from giving their newborn grandbabies tribal marks. Tribal marks as seen as symbols of identity pose hazards to the health of the newborn because the wounds are likely to become infected and the child may also develop keloids. Therefore, it is important for nurses and midwives to educate household members including mother in-laws and mothers on the harmful effects of tribal marks on newborn babies. Also, some mother in-laws described the act of forcing newborn babies to drink herbal concoctions to be bad and was considered as outmoded for their newborn grandbabies. This finding is consistent with previous studies (Abasimi et al., 2014; Bucher et al., 2016). This act of practice is harmful to the health of the newborn baby as they are likely to suffer from respiratory distress and eventually may die. Also, not just the act of forcing newborn babies to drink these 90 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES concoctions that is harmful, but herbal concoctions are generally not healthy for the growth and development of newborn babies. Therefore, mother in-laws should be discouraged from giving their newborn grandchildren these herbal concoctions to drink. Furthermore, findings from this study revealed that, some participants were uncertain with traditional newborn care practices. Some of the mother in-laws revealed that, they seek help from Traditional elders and TBAs for local treatment but when these local treatments become unsuccessful, they then resort to seek help from healthcare facilities. Also, some mother in-laws indicated that, they do not delay to send their newborn grandbabies to the healthcare center when the need arises after going for traditional treatment. This finding is consistent with previous studies (Buser et al., 2020; Jenifer & Benjamin, 2019; Premji et al., 2014; Sivalogan et al., 2018) where informal care takers found themselves in difficult situation to make decisions between medical healthcare and their traditions. This indicates that, the first person to be called in this community to offer treatment to newborns who are ill is the traditional herbalist or TBA. This is an indication that, mother in-laws evaluate medical care as an alternative for caring for their newborn babies as their second options. Participants might have identified available needs to satisfy their responsibilities for medical health care services for their newborn grandchildren, but they are also duty-bound to meet their family and traditional responsibilities. Paradoxically, this state of uncertainty is seemingly influenced by these mother in-laws cultural context and their beliefs. It is common in the Ghanaian context to give newborn baby water to drink during bathing. It was uncovered from the findings of this current study that, mother in-laws were willing to give their newborn babies water used for bathing to drink. Previous studies reported similar findings (Ferreira et al., 2018; Locks et al., 2015). However, the mothers in-law found themselves 91 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES indecisive when they had the feeling that, the water used for bathing the newborn babies is unhygienic for the baby to drink as also reported in the literature (Ferreira et al., 2018). These mixed feelings of the mother in-laws may be attributed to the fact that, they may want to quench the thirst of their newborn grandchildren but they also considered the water to be used as likely to be contaminated because it is the same water used to bath the baby. As part of the health education, mother in-laws should be educated on the composition of breast milk for them to understand that, breastmilk contains enough water to quench the thirst of the newborn baby. 5.3. Beliefs of mother in-laws about Traditional Newborn Care (TNC) practices (SN) Traditional practices are learned values, norms and beliefs that influence the way of life of a group of people in their thinking, decisions, and behaviours. These current findings disclosed that, majority of mothers in-law had a lot of varied beliefs about newborn care practices. Apparently. Participant’s way of newborn care practices reflected their values and beliefs that existed among them. These beliefs were classified into three; beliefs/ perceptions about newborn care, spirituality about newborn care and traditional norms about newborn care. Findings from this current study revealed that almost all mother in-laws held the belief that the first breast milk (colostrum) was cursed and as such it was described as “bad milk”. Similarly, studies conducted among informal caregivers in other parts of Africa (Aborigo et al., 2012; Gupta et al., 2015) and Abroad (Acharya & Meena, 2016; Ahmad et al., 2012; Corbett & Callister, 2012; Locks et al., 2015; Subbiah & Jeganathan, 2012; Thu et al., 2012; Wanjohi et al., 2017) have also revealed that it was a taboo for a newborn baby to be breastfed with colostrum and for that reason they discarded the colostrum. However, contrary to the findings from this current study, majority of informal caretakers are reported to have fed their newborn babies with colostrum with the belief that the first breastmilk contains nutrients that protect the newborn 92 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES from diseases like physiological jaundice and good for the growth and development of the baby (Agunbiade & Ogunleye, 2012; Chhetri et al., 2019; Gul et al., 2014; Jenifer & Benjamin, 2019; Kavle et al., 2014; Nethra & Udgiri, 2018). Discarding the colostrum part of breast milk deprives the newborn from the natural antibodies to fight against diseases, therefore making these newborn babies vulnerable to infections. This is also an impediment to exclusive breastfeeding practices in the community. Therefore, encouraging Exclusive Breast feeding among mother in- laws and the benefits of colostrum to newborn babies should be of great importance to nurses and midwives. Interestingly, welcoming strangers with a bowl or calabash of drinking water is a practice that is common among the northern tribes of Ghana with the belief that the stranger is being accepted to stay with them. In line with this, the current findings also revealed that, mother in-laws held a belief of welcoming their newborn babies with cow milk or millet flour mixed with shea butter oil as they believed it was ancestral feeds. Similarly, this current finding is consistent to a study conducted among informal caregivers in India and Brazil, where most newborn babies were fed immediately after birth with animal milk, hot water and mustard oil to welcome them before initiating breastmilk (Corbett & Callister, 2012; Oliveira et al., 2015). Also, newborn mothers were confronted with inaccurate traditional beliefs about newborn care practices which made them to give herbal concoctions to their newborn babies after birth (Agunbiade & Ogunleye, 2012). However, the current findings are inconsistent with previous studies as literature suggests that prelacteal feed was not given to majority of newborn babies as reported in previous studies (Devkota & Bhatta, 2011; Karmacharya et al., 2017). Exclusive breast feeding is an important behaviour and should start within an hour after delivery until the baby is six months old. 93 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Obviously, these beliefs of mother in-laws giving prelacteal feeds interrupts the practice of exclusive breastfeeding and exposes the newborn to gastric infections. Also, findings from this current study revealed that, mother in-laws held the belief that, newborn babies grow up to be pious and God fearing when verses of the Holy Qur’an (Islamic Book) is recited into their ears immediately after birth. Similarly, this belief of using the Islamic verses to welcome newborn babies was reported in previous studies (Ratanasombat, 2008; Zeyneloğlu & Kısa, 2018). However, it was reported in another study that a key obstacle to institutional delivery was the denial of Azan (calling for prayers by reciting verses of the Qur’an) by religious leaders to welcome newborn babies (Ababor et al., 2019). The practice of welcoming newborn babies with verses from the Qur’an is harmless to the health of newborn baby. Probably, this religious practice may be influenced by the predominant nature of Islam in the North Gonja District. To build up participation in all health promotion steps, it is important for healthcare providers at the family and community level to understand and adopt appropriate religious practices during health promotion activities. Another cardinal finding from this current study was the practice whereby newborn babies were confined indoors by mothers in-law until the babies became 40 days old with the belief that, they are protecting the newborn from the curse of evil spirits as reported in previous studies (Bangari et al., 2019; Jenifer & Benjamin, 2019; Nisha et al., 2019; Reshma, 2014; Sharma et al., 2016). Similarly, a study conducted in Zambia revealed that it was a traditional norm for newborn babies to be indoors for about 2 weeks to 3 months period (Sivalogan et al., 2018). These practices of confining the newborn babies and their mothers in the room helps to increase bonding and keeps the newborn warm. However, continuously keeping the newborn baby in seclusion is likely to deny the baby from receiving care from the postnatal clinics, since the 94 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES duration of staying indoors spans more than a month. This may prevent the newborn baby from most of the immunization schedules and other health monitoring activities done at the postnatal clinics. Therefore, Nurses and midwives should integrate these beliefs into routine home-visits activities such that they can provide medical care to these babies confined in their comfort zones. Also, healthcare providers in this area of the study should encourage mother in-laws to bring newborn babies to the postnatal clinics by covering their eyes since that is likely not to interfere with their beliefs. In Ghanaian Muslim communities, official naming of the baby into the family and the community usually occurs on the 8th day after birth. On this day, external family members and friends are invited by the child’s family to witness the religious naming of the child and then make merry afterwards. Also, religious rites are performed on the newborn baby on this ceremonial day. Findings from this current study revealed that mothers in-law considered the hair of their newborn babies to be “bad hair” and as such the newborn baby’s hair must be shaved on the day of their naming ceremony as similarly reported by several studies (Bandyopadhyay, 2009; Benkheira, 2017; Mohyuddin & Munir, 2015). The practice of shaving the hair of the newborn can be attributed to the religious beliefs of these mother in-laws. Majority of people living here have imbued both Islamic and traditional religions into their daily schedules which has become part of them. However, shaving the hair of the newborn baby may predispose the newborn baby to cold and loss of body heat since the area at that time of the study was windy and cold due to the harmattan season. This may lead to hypothermia of the newborn baby and therefore mother in-laws should be discourage from endangering newborn babies survival with such practices. 95 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES These current findings revealed that majority of mothers in-law indicated that giving tribal marks on the face, arms, legs and abdomen was considered to be one of the commonest beliefs for tribal identification. This finding is consistent with studies (Cullivan, 1998; Garve et al., 2017) where tribal marks were given for identification purposes. It is clear that, this belief of tribal marks as symbols of identification by mother in-laws is rooted in the anecdotal historical perspectives of the then royals of Gonja land invaders who gave their followers marks to differentiate them from other tribes. It is therefore imperative for healthcare workers in this community and other areas to seriously campaign against this practice by elaborating on the hazards of these practices on newborn babies. The question that remains unanswered for now is that, are the instruments used for these tribal marks safe? Therefore, it is recommended that, further studies should be conducted in this area to ascertain these factors. Another interesting finding was the beliefs about the period to start bathing the newborn after birth. Mother in-laws believed that it was forbidden at night to bath the newborn baby immediately after birth. This finding from the current study is inconsistent with the recommendation by the World Health Organization that, bathing of every newborn baby after birth should be delayed for about 72 hours in order to keep the baby warm and to prevent hypothermia (EveryNewBorn, 2014). This belief is harmless to the newborn baby, even though, the duration (within 12hours) for delayed bathing may be short. Retaining heat of the newborn baby was for only few hours at night and for only babies born at night time. This implies that babies born during day time are immediately bathed. Understanding the importance of delayed bathing as a practice that extends beyond one night is essential to preserve the warmth of the newborn baby. Therefore, mother in-laws in the study area and other areas should be encouraged to practice delayed bathing of their newborn grandbabies according to the recommended period. 96 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Furthermore, a finding from this current study was that, mother in-laws believed it was a taboo for a widow who has not gone through the widowhood rites to come closer to the newborn baby. The participants believed that, these widows are unclean and may possess evil spirits who can spiritually harm their newborn grandbabies. Similarly, a study conducted in Jordan by Mrayan et al. (2018) also revealed that newborn babies were protected by caretakers from people with evil eyes from coming closer to them. The belief of protecting newborn babies is harmless and this may also prevent cross transmission of diseases. The skin of the newborn is fragile and proper care should be taken to protect it. Furthermore, majority of mothers in-law were engaged in ritual rites performed by traditional elders on their (mothers in-law) breasts known as “breasts washing” to stimulate their breasts for milk production in situations where their daughter in-law dies leaving the newborn baby as also reported by Aubel (2021) where grandmother were engaged in traditional practices to stimulate the production of breast milk for their newborn grandchildren to be fed on. The thinking of mother in-laws to continuously breastfeed their newborn grandchildren with Human milk was a good idea. However, mother in-laws should be encouraged to seek help from the nurses and midwives in such difficult situations. Another interesting finding from this current study was that mother in-laws indicated that animals were sacrificed to appease their shrines or their ancestors as means of initiating their newborn grandbabies into their spiritual family. It is a common practice in the Ghanaian society to name a child after a shrine’s name which is usually recommended by the family traditional priest or soothsayer. These spiritual practices have no negative effect on the health of the newborn baby since the blood of the animals sacrificed are only used to touch the forehead of the newborn baby signifying acceptance from the ancestors. 97 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Also, some mother in-laws believed that newborn babies who cries excessively after birth should ritually be given names of their great grandparents after consulting traditional priests. In contrast, a study revealed that, grandmothers believed that excessive crying of newborn babies to be pangs of hunger due to insufficient breastmilk and they attended to such newborn babies by giving them artificial feed (Angelo et al., 2020; Kavle et al., 2014). Mother in-laws should be encouraged to send their newborn grandbabies to the healthcare facilities for examinations and diagnoses. Interestingly, findings from this current study revealed that mother in-laws believed in some rituals like tying threads with cowries around the waists and wrists of their newborn grandbabies to protect them from evil spirits. This finding is consistent with previous studies conducted in India, where ritual ceremonies were performed using small ropes tied around the newborn baby’s neck, wrist or ankle, putting amulets on the waist and abdomen and placing items at the entrance of the doors repel evil spirits (Cacodcar et al., 2015; Corbett & Callister, 2012; Jenifer & Benjamin, 2019; Latha et al., 2017). These beliefs of mother in-laws are harmless to the newborn baby. However, the cowries attached to the threads may cause discomfort when newborn baby lay on them. Also, the thread may be tied too tightly which may impede proper blood circulation to those parts of the body. Traditional norms are the common values and beliefs shared within a family or community that are inherited by the current generation from older generations. Finding from the current study revealed that, majority of mothers in-law maintained traditional norms that were handed over by their grandparents, parents and mothers in-law and elderly people in their community in the care of their newborn grandbabies. Similarly, studies from both Africa (Sichimba et al., 2017) and abroad (Oliveira et al., 2015) indicated that, grandmothers who were with more distinctive 98 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES traditional norms alignment were engaged in the care of their newborn grandbabies during the postnatal periods. Recognizing family or community norms in the postnatal periods aids healthcare providers to properly organize their health promotion activities to be consistent with their traditional context in which they provide their services. 5.4. Perceived behavioural control of mother in-laws TNC practices Mother in-laws are perceived to be the reservoirs of knowledge when it comes to newborn care due to their previous engagements in the care of newborn babies. Planned activities, availability of resources, intrinsic motivations, skills and knowledge had an influence on mother in-laws confidence to perform a behaviour. Mother in-laws who perceived certain newborn care practices to be easy to perform demonstrated high control over their behaviours whilst those who perceived practices to be difficult to perform demonstrated low control over their behaviours. Therefore, these controls of behaviour were categorized into two; high perceived control about newborn care practice and low perceived control about newborn care practices. In the African society, grandmothers who care for their newborn grandbabies are usually seen to have more knowledge and skills in performing TNC practices due to their previous experiences on newborn care over the years. Findings from this current study revealed that mother in-laws expressed their feelings of performing newborn care practices with ease because they claim they possess more knowledge and skills on TNC practices. This finding agrees with previous studies where mothers in-law who want the best for their grandchildren assisted adolescent mothers in the care of their newborn grandbabies with much ease (Bootsri & Taneepanichskul, 2017; Iganus et al., 2015; Premji et al., 2014). These claims of mother in-laws having more knowledge and skills of TNC practices may probably be related to the fact that the Ghanaian elderly woman is always engaged in the care of her newborn babies after delivery. For this reason, healthcare 99 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES providers should incorporate mother in-laws in their health promotion activities plans in order to achieve essential newborn care practices at home. Another cardinal finding this study discovered was that some mother in-laws were of the view that they would be able to perform newborn care practices with more ease when resources for the care of newborn babies are locally available. Studies among Central Nepal and the city of Caceres informal caregivers revealed similar practices (Karkee et al., 2014; Oliveira et al., 2015). However, unlike mother in-laws who acquired herbal concoctions with ease and less expensive in this current study area, the Nepal women in both their rural and urban communities relied on available local resources like cow or buffalo milk as substitute for infant formula. The city of Caceres informal caregivers were able to solve breast feeding problems by local available resources. In the Ghanaian traditional homes, caring for a newborn baby requires a lot of items which are supposed to be readily available before and after the birth of the baby. These gathered materials tend to make newborn care easy for informal care givers. Therefore, mother in-laws and mothers should be guided by nurses and midwives on the kind of newborn care items to be organized. Also, with the use of the herbal preparations, it is important for nurses and midwives to educate mothers in-laws on optimal newborn practices in order to safeguard newborn babies from harmful traditional newborn care practices. The current study uncovered that mothers in-laws were having more passion and love towards the care of their newborn grandbabies. Similarly, informal care takers were strongly engaged in traditional newborn care practices with ease because of their intrinsic motivation like happiness, joy and benefits of good health associated to the care of newborn babies (Gallegos et al., 2015; Russell et al., 2016). A study conducted in Egypt presented a contrary view (Kavle et al., 2014) where many informal caregivers were afraid of performing some traditional newborn care 100 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES practices like introduction of family foods to babies at 6 months old. It is with a great joy for grandmothers in the Northern Ghanaian society to play with their grandchildren with the male children as their husbands and the female children as their rivals. This joy and happiness within these grandmothers are translated into the best care rendered to their grandchildren as it is assumed to be their responsibility. Another hurdle observed in the current study indicated by mother in-law was financial constraint (poverty) as the main gap in the care of the newborn baby. The participants indicated that, they may have interest in acquiring some newborn care items like soaps, baby dresses among others but due to lack of money, they are unable to buy some of these items which makes it difficult for them in the care of their newborn grandbabies. This finding is supported by the studies of Ferreira et al. (2018) and Locks et al. (2015) where it was revealed that grandmothers were in support of newborn care practices, however other factors like cultural and financial constraints influenced their ways of newborn care practices. In addition, despite the love of parents for their children, fathers in Pakistan found it difficult to take care of their newborn babies because they were poor (Premji et al., 2014). Conversely, a study conducted in Nigeria revealed that about 52% of participants received high level of financial support from family members in the care of their newborn babies (Agudile et al., 2020). In situation like this, mother in-laws are likely to use all sort of materials that are available to take care of their newborn grandbabies. Therefore, all mother in-laws and mothers in this area of study and other areas should be empowered financially by fathers of these babies in order to plan and organize these items before and after the birth of their grandchildren. Also, the current study revealed that some mother in-laws had the perception that caring for newborn babies become difficult for them in situations such as having a pair of twin newborn 101 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES babies, when the newborn baby is ill, when the mother of the baby dies, and when the baby is given immunization injections. These situations are probably going to interfere with the care of the newborn baby and therefore making it difficult to care for such babies. Therefore, family members should be encouraged to support mothers and mothers in-law in the care of their newborn grandbabies. Healthcare provider should identify newborn babies with these special problems for home-visiting in order to give health education and guidelines to mother in-laws on how to care for newborn babies in such difficult situations. 5.5. Intentions of mother in-laws towards TNC practices Planning and organization are common practices in every formal organization by managers or leaders. However, to translate this into our homes, mother in-laws are seen as the managers of home affairs for their roles and functions are not just to cook and feed their family members but also, they plan and organize newborn care items before and after the birth of their grandchildren. Mother in-laws with strong intentions about particular TNC practices were likely to be engaged in such practices. Majority of participants had plans towards the care of their grandchildren before they were born. Some mother in-laws also had the intentions to continue to execute some of these plans after delivery whilst other participants had changes in their plans after delivery. These plans of mother in-laws were categorized into; plans before the birth of baby, plans after the birth of baby and changes in plans after delivery of the baby. A crucial finding from this current study revealed that almost all mother in-law had the intention to organize newborn care items like soaps for bathing, shea butter oil as pomade, gathered old clothes as napkins waiting to be used on their newborn grandchildren. This finding is consistent with a study in Zambia where mothers were expected to buy newborn care materials and tools to be used during delivery regardless of place (home or facility) they desire to deliver (Herlihy et 102 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES al., 2013). In addition, the participants revealed that they intended to gather foodstuff like groundnut paste, Aniiri, that would be used to prepare nutritious meals for their daughter in-laws in order to stimulate the production of more breastmilk during puerperium. This finding is consistent with a meta-synthesis study (Angelo et al., 2020) where grandmothers recommended foods, beverages and special products in larger amounts for newborn mothers to consume in order to produce breastmilk in large quantities. Contrary to this finding as reported in literature, newborn mothers were encouraged by mothers in-law to breastfeed their babies with colostrum immediately after delivery with the intention of stimulating maternal breast milk production (Sychareun et al., 2016). Conversely, newborn mothers were advised not to eat certain foods like cold foods and spicy foods as it may decrease breastmilk production (Begum, Sebastian, Kulkarni, Singh, & Donta, 2017). Mother in-laws intentions of organizing items and food that would be used during puerperium for both the newborn and their mothers is a good practice. The ideal is that, pregnant women who attend the antenatal clinics are usually informed on the items they are supposed to bring during labour and the kind of local available food they are supposed to eat after birth to increase breast milk. Furthermore, findings from this current study uncovered that for the purpose of safe delivery coupled with the intention of taking care of newborn babies, paternal grandmothers requests for their daughter in-laws whose gestational periods are usually around the third trimester to move and stay with them in their rooms. This finding agrees with Falnes et al. (2011) where it was reported that the custom of a daughter in-law after giving birth moving in to stay with her mother in-law was commonly practiced. In contrast, a study in India disclosed that pregnant women leave their husband’s to their mothers home for the remainder of their pregnancies, birth and extending to several month for postpartum period before returning to their husband’s 103 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES families (Corbett & Callister, 2012). The practice of pregnant daughter in-laws moving in to stay with their mother in-laws is a harmless norm that is common among most tribes in Northern Ghana. These elderly women may intend to offer assistance to their daughter in-laws by performing their house chores and also assist them during labour especially those mother in-laws who are TBAs. Also, mother in-laws who are TBAs should be empowered by healthcare providers with more knowledge to enhance their competency on delivery and immediate newborn care so that in urgent situations, they can conduct safe deliveries at home with little supervisions from the nurses and midwives. Also, findings from this current study, revealed that some mother in-law intend to continue to practice traditional newborn care practices that were left behind for them by their parents. The participants indicated that they have no intentions of abandoning their traditional practices for their newborn grandbabies yet-to-be born. Similarly, previous literature suggest that grandmothers played traditional specific roles in advising and directing caregivers on how to care for their newborn grandchildren (Aubel, 2021). Another study conducted in Nigeria among informal care takers revealed that mothers intended to continue to breastfeed their newborn babies up to a year (Agunbiade & Ogunleye, 2012). These intentions of the mother in-law maybe influenced by their traditional beliefs and values which are significantly regarded in high esteem. Therefore, mother in-laws should be encouraged by healthcare practitioners to perform newborn care practices that are healthy for the newborn baby and practices that are detrimental to the health of the newborn should be discouraged. The current study also discovered that some mothers in-law were willing to teach and coach their daughters in-law on newborn care especially newborn mothers who were novice as also reported among women in Nigeria (Agudile et al., 2020) and among adolescent mothers in Thai (Bootsri 104 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES & Taneepanichskul, 2017). It is assumed to be the responsibility of grandmothers to support newborn mothers after delivery especially newborn mothers who are novice in terms of newborn care. Assisting the newborn mother in the care of the baby during puerperium may help newborn mothers to recover physiologically and psychologically. For this reason, healthcare providers should encourage other family members to assist in the care of newborn babies especially in the case of twins as it may help mothers to recover quick and prevent them from postpartum complications. It is normal among humans to amend their behaviours when the outcomes did not go as they have planned. Findings from this current study revealed that majority of participants were of the view that, their plans have not been amended and they were still adhering to their initial plans. Similarly, a study conducted in Nepal among mothers and mothers in-law suggested that in order to reduce newborn morbidity and mortality, expectant mothers should develop birth preparedness plan (Tiwari et al., 2014). Mother in-laws with single newborn babies usually do not struggle so much to take care of their newborn babies because everything is working according their plans. They only need to add other items into their existing plans when the need arises. On the other hand, the current study revealed that two of the participants who were with a pair of twins each had their plans changed. Similar finding was reported in a study by Edmond et al. (2018) where mothers had changes in birth preparedness and newborn care. In situations like this, grandmothers usually become worried and are compelled to use all sort of resources in the care of the newborn babies in order to compensate the situation at hand. 5.6. Behaviour of mother in-laws on traditional newborn In this current study mother in-laws behaviours were either influenced by array of factors like their beliefs and intentions about newborn care. Majority of mothers in-law demonstrated actual 105 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES control over their behaviours in some aspects of newborn care practices. These practices compared to standards of newborn care may either be beneficial or harmful to the newborn baby. An interesting finding from this current study was that, majority of the mother in-laws applied various substances like shea butter oil or tailor oil mixed with Chloramphenicol or amoxicillin, shea butter mixed with “akumadada” applied on the umbilical cord, circumcised penis, fontanelles and tribal marks. The current finding is consistent with several studies (Aborigo et al., 2012; Adama et al., 2018; Berhea et al., 2018; Degefie et al., 2014; Osman et al., 2018; Saaka & Iddrisu, 2014) where informal care takers applied locally available substances on their newborn babies’ umbilical cords. In contrast, a study in southern Tanzania disclosed that applying nothing to the newborn umbilical cord were the common practices (Penfold et al., 2014). The participants reasons for applying those local substances on their newborn babies can be related to the availability of those resources and the belief that those substances heal the wounds on the newborn babies faster. Applying these local substances on the newborn babies may exacerbate the probability for the development of neonatal infections like septicemia, tetanus omphalitis and therefore impedes the survival of the newborn born baby. Healthcare providers should recommend the use of chlorhexidine cream for the care of the umbilical cord. In addition, majority of mothers in-law indicated that herbal concoctions and written Islamic verses washed into water (Walga) were given to newborn babies to drink whilst some were used to bath their newborn grandbabies as remedies for their grandbabies when they are ill and all these are not different from traditional practices reported in previous literature (Gee et al., 2018; Reshma, 2014). Conversely, it was reported in a study that informal care takers of newborn babies did not use any form of local remedy to treat their babies whenever they were sick, but they rather sought help from medical practitioners (Çapik & Çapik, 2014). 106 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Another cardinal finding from the current study was that, mothers in-laws were so much concerned about the cleanliness of their newborn babies. Almost all the mother in-laws who had their newborn babies delivered at home were given immediate bath. Consistent findings to this current finding were found in studies conducted in some African countries (Adejuyigbe et al., 2015; Degefie et al., 2014; Mukunya et al., 2019) and abroad (Hunter et al., 2014; Smittenaar et al., 2020). Contrary, previous studies reported by Berhea et al. (2018) and Hill et al. (2020) were delayed bathing as a culturally accepted practice by grandmothers. Furthermore, a study conducted in India (Corbett & Callister, 2012) revealed that mothers were engaged in delayed bathing of their newborn babies for a period of 9 days or 3 months. Immediate bathing of newborn babies are practices that are detrimental to the health of the newborn baby and as such healthcare professionals should discourage mothers and grandmothers from such practices. Similarly, preventing cross-infections from mother in-laws to their newborn grandbabies was of much concern for some of the mothers in-law. Findings from the current study uncovered that some mothers in-law washed their hands with soap and water prior to bathing of newborn babies as similarly reported in previous studies (Chhetri et al., 2019; da Silva et al., 2013; Hanson et al., 2015). The findings of the current study is inconsistent to previous literature that reported that TBAs and caretakers who were attending to newborn babies after delivery had their hands uncleaned (Dhingra et al., 2014). Newborn babies are vulnerable to infections due to their delicate skins and lower body immunity. Mother in-laws washing their hand before handling their newborn grandbabies is a good practice and should be encouraged among all other informal care takers by Nurses and Midwives. Furthermore, the current study revealed that during bathing, mother in-laws clean the umbilical cords and circumcised penis of their newborn grandbabies, massages their bodies with shea 107 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES butter. Previous studies suggest similar findings as reported in literature (Jenifer & Benjamin, 2019; Peterside et al., 2015; Walsh et al., 2015). In contrast, studies conducted in both Africa (Gee et al., 2018; Reshma, 2014) and abroad (Smittenaar et al., 2020) revealed that unhygienic instruments were used to cut newborn babies umbilical cords during deliveries and clean cord care was also not practiced after delivery. Practicing clean cord on newborn babies would prevent them from cord infections as recommended by the Word Health Organization. Also, massaging the bodies of the newborn babies would stimulate blood circulation. However, excessive massaging and stretching of the baby can lead to injuries and dislocations of joints. Therefore, mother in-laws should be encouraged to continue to keep their newborn babies umbilical cords clean and massaging should be done in moderation. Interestingly, the current study revealed that all newborn babies were breastfed. However, majority of the newborn babies were denied of colostrum. Similarly, previous literature suggest that newborn mothers breast milk (colostrum) was expressed and discarded before the initiation of breastfeeding (Degefie et al., 2014; Gee et al., 2018; Memon et al., 2019; Sharma & Byrne, 2016). Conversely, several studies revealed that mothers and grandmothers indicated that colostrum was good for the growth of babies and ensured their newborn babies were breastfed with colostrum within an hour after delivery (Chhetri et al., 2019; Gul et al., 2014; Jenifer & Benjamin, 2019; Khan et al., 2013). Discarding colostrum may precipitate the initiation of prelacteal feeding. Therefore, mother in-laws should be discourage from this practice. Finding from this current study discovered that majority of mothers in-law gave prelacteal feeds to their newborn babies after denying them the first breastmilk as also reported in previous literature (Bootsri & Taneepanichskul, 2017; Hunter et al., 2014; Karmacharya et al., 2017; Locks et al., 2015; Memon et al., 2019). On the contrary, studies conducted among informal care 108 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES providers also revealed that breastfeeding was seen as necessary and irreplaceable food to meet the child’s nutritional needs and as such newborn babies were not given prelacteal feeds (Angelo et al., 2020; Chhetri et al., 2019; Devkota & Bhatta, 2011). Another cardinal finding from this current study was that some mothers in-law indicated that they fed their newborn grandbabies who were less than 6 months with adult foods which seems to be a common practice among grandmothers (Aubel, 2021; Ferreira et al., 2018; Nunes et al., 2011). However, exclusive breastfeeding was commonly practiced among informal care providers in Northern Ethiopia (Berhea et al., 2018). Whiles certain traditional newborn care practices are beneficial, others like introduction of prelacteal feeding and discarding of colostrum interrupts with exclusive breastfeeding process. Prelacteal feeding may also predispose newborn babies to diarrhea infections. It is therefore important for Nurses and midwives to educate all informal care providers on the importance of colostrum and exclusive breastfeeding to newborn babies. It was worth noting in this current study that, despite mother in-laws not practicing exclusive breastfeeding for their grandchildren, they deemed it necessary for their newborn grandchildren to have enough breastmilk to feed on. Some mother in-laws indicated that they prepared delicious meals like millet porridge (pampa) and TZ with groundnut soup for their daughter in- laws to in order to increase breastmilk production during the early days after delivery. This practice was also reported among grandmothers in Ethiopia (Degefie et al., 2014) and American- Indian community (Houghtaling et al., 2018). Therefore, Nurses and midwives should encourage mothers and mother in-laws to identify and use locally available foodstuffs that has the potential to increase breastmilk production. Findings from the current study revealed that some of the participants in an attempt to prevent their newborn grandbabies from hypothermia, involve beneficial practices like wrapping their 109 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES newborn grandbabies immediately after delivery, bathing newborn babies with warm water and keeping room warm with charcoal fire for the entire night as similarly reported in previous studies (Adejuyigbe et al., 2015; Degefie et al., 2014; Jenifer & Benjamin, 2019). However, previous studies argued that newborn babies were not dried and wrapped immediately after birth (Dhingra et al., 2014; Shamba et al., 2014). Recommendation from W.H.O. suggest that bathing of every newborn baby should be delayed for a period of about 72 hours in order to keep the baby warm and to prevent hypothermia (EveryNewBorn, 2014). Heat is loss from the newborn baby immediately after delivery due to evaporation of amniotic fluids. Therefore, mother in-laws and other informal care takers should be encouraged to immediately dry and wrap newborn babies even before cutting their umbilical cord to prevent hypothermia. Immediate bathing should be discouraged among mother in-laws in this area of study and other areas as well. 5.7. Knowledge of mother in-laws on Essential newborn care (ENC) practices Majority of the participants had varied information from different sources about newborn care. Those who had more information on essential newborn care practices are likely to emulate such practices. Majority of the participants stated that, they had newborn information from informal referent others whilst some of the participants had received newborn information from Nurses and Midwives. Generally, there was poor source of information on essential newborn care practices among mother in-laws. In Northern Ghana, mother in-laws act as substitutes for healthcare providers in proving healthcare information for their newborn grandbabies and their daughter in-laws. Findings from the current study revealed that majority of mother in-laws only received teachings and information related to newborn care from their family members, TBAs and friends as also reported in previous literature (Degefie et al., 2014; Hill et al., 2020; Moyer et al., 2012). 110 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES However, literature from previous studies argued that most maternal education on newborn care were received during pregnancy at the antenatal clinics and postnatal periods from healthcare professionals and also from media health programmes and local television channels (Amolo et al., 2017; Kavle et al., 2014; Wambach et al., 2016). Community mobilization via women groups and community volunteers are ways to institute community approaches to improve newborn care practices. Therefore, the need to reinforce the health system in this area of the study. Also, some of the participant disclosed that the distance from their homes to the healthcare facilities was far. However, some participants indicated that the nurses and midwives occasionally visit them at their home without giving them information on how to care for their newborn babies. Consistently, studies conducted in both Africa (Chichiabellu et al., 2018) and Asia (Edmond et al., 2018) revealed that poor access to newborn healthcare information from antenatal clinics (ANC), Postnatal clinics (PNC) and lack of information about newborn dangers signs contributed to poor coverage of essential newborn care practices. Therefore, healthcare providers should link up with Grandmothers and TBAs to promote and increase health education on essential newborn care practices. Mothers and mother in-laws should be encouraged to utilize ANC and PNC services. Another interesting finding from the current study revealed that some mother in-laws were having misconceptions about practices like breastfeeding the newborn with colostrum and exclusive breast feeding. This is similar to studies conducted among grandmothers in Thai and Tanzania (Bootsri & Taneepanichskul, 2017; Falnes et al., 2011). Also, similar reports from literature by Angelo et al. (2020) and Corbett and Callister (2012) revealed that grandmothers discarded colostrum because they think it was an old milk stored in the breast for long period and also hard to digest. Nursing a newborn baby for 6 months without water to drink is a practice 111 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES most mothers in-law probably may think their newborn grandbabies would be starved with thirst. Therefore, the perception of mother in-laws about these practices elicits a need to educate them and their daughters in-law on the importance of exclusive breastfeeding. Furthermore, some mother in-laws were able to demonstrated some knowledge on optimal newborn care practices like exclusive breast feeding as reported in previous studies (Berhea et al., 2018; Buser et al., 2020). Mother in-laws might have demonstrated some level of knowledge on optimal newborn care practices, however, their cultural background and beliefs may have influenced their decisions regarding newborn care. Therefore, there is the need to educate not only the mothers in-law but also the family as a unit regarding harmful practices whilst emphasizing on the components of essential newborn care practices. 5.8. Authority of mother in-laws over TNC practices Majority of mothers in-law demonstrated authority over newborn care choices. They exhibited power in the care of their grandchildren even when it was against the wish of their sons and daughter in-laws. However, most of the participants indicated that their ways of practicing newborn care was influenced by the informal referent others. This authority was exercised in two categories; decision about newborn care and societal pressure on newborn care. The ideal is that decisions about the care of a newborn baby is a collective responsibility on the father and mother of such a baby. However, in rural northern Ghana paternal grandmothers have control over the care of their newborn grandchildren and their decisions and orders about newborn care practices must be respected by their sons and daughter in-laws. Mother in-laws’ decisions on newborn care were observed in this current study. The mother in-laws disclosed that their decisions on how to care for their newborn grandbabies was a must for their daughter in- laws to accept. This finding agrees with previous literature (Hunter et al., 2014; Jenifer & 112 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Benjamin, 2019; Zheng et al., 2019). Also, this finding is consistent with other previous studies (Aubel, 2021; Falnes et al., 2011; Moyer et al., 2014; Premji et al., 2014) where newborn mothers sought advice about newborn care practices from revered and authoritative grandmothers. However, previous studies reported different perspectives about decisions on newborn care practices (Edmond et al., 2018; Ferreira et al., 2018; Odom et al., 2014). In northern Ghana, the culture and tradition frowns on mothers who oppose or challenges their mother in-laws decisions regarding newborn care practices. One can infer that the mother in-law has authority and great potential to effect positive influence in the establishment and preservation of optimal newborn care practices as long as they acquire knowledge and adequate skills. Another cardinal finding from this current study was that majority of mother in-laws were also influenced by their traditional norms. Consistently, previous studies conducted in Africa and Europe revealed similar findings (Falnes et al., 2011; Hill et al., 2020; Sivalogan et al., 2018; Wambach et al., 2016). Also, another previous study conducted among women in India indicated that grandmothers’ decisions on newborn care were influenced by their culture and traditions (Corbett & Callister, 2012). Even though, mother in-laws maybe influenced by their traditional beliefs and values to provide traditional newborn care to their grandchildren. However, their decisions on some of the newborn care practices may not be scientifically proven. Also, findings from this current study revealed that majority of participants were influenced by informal referent others like their family members, and friends towards newborn care practices as reported in previous studies (Agunbiade & Ogunleye, 2012; Aubel, 2012; Karmacharya et al., 2017; Wambach et al., 2016). Also, a study conducted among healthcare professionals and voluntary workers revealed that grandmothers were identified as great influencers on newborn mothers over newborn care practices (Bernie, 2014). In the Ghanaian context, newborn care 113 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES practices are usually influenced by close family members and friends. These people in the community tend to give all sort of pressure to the newborn mothers regarding the care of the newborn baby. 5.9. Summary It was revealed in the current study that majority of mothers in-law were engaged in TNC practices. The discussion discovered that mother in-laws revealed positive appraisal, negative appraisal and uncertainty attitudes about TNC practices. Also, some mother in-laws in the current study exhibited high perceived control whilst others showed low perceived control about TNC practices. In addition, mother in-laws disclosed various intentions towards TNC practices like plans before birth of the newborn baby, plans after the birth of the newborn baby and changes in plans after the birth of the newborn baby. Furthermore, mother in-laws engaged in practices like the use of herbal concoctions, cleanliness of the newborn, feeding of the newborn and maintaining body warmth of the newborn. The discussion also covered mother in-laws knowledge about TNC practices and authority of mother in-laws over TNC practices. All the themes excluding mother in-laws knowledge and mothers in-law authority were consistent with the Theory of Planned Behaviour which was used to establish the study. 114 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES CHAPTER 6 SUMMARY OF THE STUDY, IMPLICATIONS, LIMITATIONS, CONCLUSION AND RECOMMENDATIONS This chapter presents the summary of the study, the implications of the findings to nursing and midwifery practice and nursing and midwifery research. Limitations of the study are outlined and a drawn conclusion. Finally, recommendations are made from the implications of the findings. 6.1. Summary of the study Newborn stage is critical in an individual’s life and as such essential newborn care practices are needed for the protection, growth and development of the newborn baby. However, newborn care practices are integrated into the culture of the Ghanaian society. Newborn babies constitute the majority of individuals affected by traditional practices, especially the practices that are harmful. Some of these practices can prolong the recovery period of the newborn, result in disability, disease and death of the newborn baby. Therefore, mother in-laws are assumed to be the best informal care providers for their grandchildren in various communities. For this reason, the study explored the planned behaviour of mother in-laws about TNC practices in the North Gonja District using the Theory of Planned Behaviour as the organizing framework. The constructs of this theory were used to formulate the objectives of the study. The study was conducted at Daboya using an explorative descriptive qualitative design with a purposive sampling technique. The study engaged fourteen (14) mothers in-law who met the inclusion criteria. Prior to data collection, an approved ethical clearance was obtained from the Institutional Review Board (IRB) of the Noguchi Memorial Institute for Medical Research (NMIMR), University of Ghana. The interview guide was piloted at Shinshena community to 115 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES polish the questions considering the context ahead of the main study. Information about the study was said to mother in-laws who agreed to participate in the study and they were guided to sign/thumb print a consent form prior to the interviews. An audio tape recorder was used to record all interviews after seeking for participants permission. The recorded interviews were transcribed verbatim. Concurrently, data collection and data analysis were done using thematic content analysis. The study revealed that mother in-laws exhibited certain attitudes regarding newborn care practices. It appeared that, majority of mothers in-law appraised some practices to be good whilst some appraised some practices to be bad. Others were uncertain of some of the practices either to be good or bad. Majority of participants were willing to be engaged in TNC practices they appraised to be positive for their grandchildren and disapproved those practices they appraised negatively. The study also found that almost all the participants held some form of beliefs when it comes to the care they render to their newborn grandchildren at home. Majority of participants believed in traditional practices and spiritualities that are common and accepted by all members of their family or the community at large in the care of their newborn babies. It was worth noting that, some of the participants were confident about performing TNC practices whilst others doubted their ability to perform TNC practices. Majority of the participants shared the view that financial constraints made it difficult for them in carrying out newborn care practices whilst others were of the views that, their skills and knowledge about carrying out TNC practices, and their previous experiences about TNC practices influenced them to practice TNC with ease. 116 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Furthermore, the study revealed that, majority of participants had plans towards the care of their grandchildren before they were born. Some participants also continued to execute these plans after delivery whilst others added new plans after the birth of the baby. Also, it was noted that, those with a pair of twins had their initial plans changed because they had planned to care for a single baby instead of two babies. Behaviour of participants towards newborn care was another remarkable finding of the study. Majority of mothers in-law demonstrated actual control over their behaviours in some aspects of newborn care practices. These practices as compared to essential newborn care practices may either be of beneficial or harmful to the newborn baby. Finally, it was discovered that majority of mothers in-law received traditional newborn information from their family members and TBAs. Generally, participants were having inadequate knowledge on essential newborn care practices due to inadequate health education rendered by Nurses/Midwives. When it came to authority of mother in-laws, they were the sole decision makers for newborn care choices, even when it was against the wish of their daughters in-law and sons. Pressure from the society and significant referent others influenced participants decision in rendering care for their grandchildren. These maybe the reason why majority of mothers in-law were engaged in TNC practices in the care of their newborn grandchildren. Implications The findings of this study have implications for nursing practice, nursing education, nursing administration and nursing research. 117 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 6.1.1. Implication for nursing and midwifery practice The study established that mother in-laws in the North Gonja District had inadequate source of information on essential newborn care practices. Inadequate knowledge on essential newborn care practices may be the grass root for harmful newborn care practices. It is therefore imperative on nurses and midwives to educate all mother in-laws during home-visits and durbars on essential newborn care practices and discourage them from harmful traditional newborn care practices. This education may also help in addressing the powers of mother in-laws as they were found to have total control over the care of their newborn grandbabies. Nurses and midwives should be empowered in their skills and knowledge by engaging themselves in periodic in- service training sessions in order to stay abreast with essential newborn care practices. 6.1.2. Implications for nursing and midwifery research The study revealed that traditional newborn care practices affect optimal newborn care practices among mother in-laws in the North Gonja District, Ghana. One of the dependable ways of gaining valid information and knowledge of evidence-based practice is scientific research. The quality of skills and knowledge that nurses and midwives employ in newborn care practices will become short if they do not find out the best way of rendering such services to benefit newborn babies, mother in-laws, mothers and the entire community. It is therefore imperative to understand these beliefs and practices about newborn care, hence the need for further research in the area of newborn care to explore major factors in accessing and utilizing essential newborn care practices as well as ways in solving harmful newborn care practices. The phenomenon can be a quantitative study to establish relationship between the constructs of the theoretical framework. 118 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 6.1.3. Implications for nursing and midwifery administration Nursing administrators at the regional and district level should engage all nurses and midwives by organizing periodic in-service training on newborn care practices. This will empower nurses and midwives to provide more health education and awareness on essential newborn care practices through various media to reduce harmful traditional newborn care practices. 6.1.4. Implications for nursing and midwifery education The curricula for all cadre of nursing students should be amended by the Nursing and Midwifery Council (N&MC) to include cultural related nursing courses. This will broaden the horizon of the student nurse and midwife’s knowledge with the multiple cultural diversity which will enable them carry out holistic and individual newborn care practices. 6.2. Limitations of the study The current study cannot be concluded without some limitations despite the important information it has unearthed. The study was limited to only mother in-laws who lived in the North Gonja District of Ghana. However, the setting and demographic data have been properly described to allow the cautious generalization of the findings to other similar context. Another limitation that was observed was the translation of the data from the local language to English, suggesting that some of the statements could have missed their actual meaning. Again, the study appeared to be one sided story, thus, only mother in-laws were recruited without engaging mothers of newborn babies. The Novel Covid-19 pandemic also imposed a lot challenges on the study. 119 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Conclusion The findings suggest that, mother in-laws in the North Gonja District were involved in traditional newborn care practices. Most of the mother in-laws found it difficult to avoid their traditional newborn practices because of the influence of their attitudes, traditional beliefs, societal pressure from other significant others, and their planned intentions that were uncovered. It was also established that mother in-laws have more power and authority over newborn care practices despite their little knowledge on optimal newborn care practices. These powers from mother in- laws may make mothers have low self-esteem and incapacitated in caring for their own children. The Theory of Planned Behaviour was used as the organizing framework to explore the planned Behaviour of mother in-laws about traditional newborn care practices in the North Gonja District of Ghana, and the findings reported are largely consistent with the constructs of the TPB. Therefore, mother in-laws and other family members should be educated on the benefits of essential newborn care practices and its components and the harmful effects TNC practices pose on the newborn baby. 6.3. Recommendations The following recommendations are made based on the findings of the study to the Ministry of Health (MOH)/Ghana Health Service (GHS), District Health Management Team (DHMT) and Non-Governmental Organizations (NGO). 120 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 6.3.1. Ministry of Health (MOH)/ Ghana Health Service (GHS) The MOH/GHS should ensure that: 1. The current curricula for training nursing and midwifery students are amended to include transcultural nursing and neonatal nursing. This will broaden the scope of care for the newborn baby and considering the cultural context by nursing and midwifery students after successful completion of their respective programmes. These nurses and midwives will in turn render proper health education on newborn care for mother in-laws and other informal newborn care providers. 2. They train all cadre of nurses and midwives on essential newborn care practices. This will help them provide specialized newborn care education and training to mother in-laws and mothers. 3. They provide logistics and funds for all District Health Management Team to organize culturally competent newborn care modalities for mother in-laws and other informal care providers to be abreast with skills and knowledge on essential newborn care practices in their various communities. 4. They collaborate with other stake holders like the Ministry of Gender, children and Social Protection, and Ministry of Chieftaincy, Arts and Culture to organize and sensitize women including grandmothers on the benefits of essential newborn care practices. Chiefs, Queens and their community members should be sensitized on the harmful effects of some TNC practices. This will address some of the detrimental traditional beliefs and practices that exist in their communities. 121 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 5. They empower by financially supporting nurses and midwives to upgrade their knowledge in specialty area like neonatal nursing. This will help improve their skills and knowledge on essential newborn care practices and in turn improve the knowledge and skills of mother in- laws and other informal care takers. 6.3.2. District Health Management Team (DHMT), Daboya The DHMT is under the Ghana Health Service. The DHMT should: 1. Ensure that routine home visit is compulsory for community health nurses and midwives. The home visits should target all significant others in the care of the newborn baby. The focus of the education should be centered on discouraging informal care providers on harmful traditional newborn care practices. 2. Ensure that essential newborn care manuals are available to use by nurses and midwives to educate informal care providers in the district. 3. Ensure that they organize CPD training sessions to update the knowledge and skills on essential newborn care practices for all nurse and midwives in the district. Health education from such nurses and midwives would improve the knowledge of mother in-laws and other referent others in the community. 4. Periodically engage TBAs and other traditional healers on optimal newborn care training sessions. They will in turn educate their community members who seek for their services on the need to practice optimal newborn care. 5. Organize durbars in various sub-district to educate and train informal care providers on optimal newborn care practices. 122 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 6. Encourage nurses and midwives at the ANC and PNC units to educate mothers and mothers in-law or grandmothers on the need to utilize the services at the clinics during pregnancy and after child birth. This will help in the proper monitoring of the growth and development of the baby and mother before birth and after birth. 7. Ensure that monthly reports from the sub-districts on growth monitoring of newborn babies, morbidity and mortality are sent to the district health officer. This will help identify sub- district that are performing well and immediate support would be given immediately. 6.3.3. Non-Governmental Organizations (NGOs) The NGO should: 1. Support the district health services to provide contemporary health education on newborn care practices via the mass media. 2. Sponsor programmes related to newborn care practices within their purview. 3. See harmful traditional newborn care practices as a public concern, since that is one of the causes of neonatal morbidity and mortality in most African countries. 4. Support in the cost of upgrading nursing and midwifery education on courses related to newborn care. 5. Support in girl-child education, since illiteracy is one of the factors among older women that impedes essential newborn care services in the community. 123 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES REFERENCES REFERENCE Ababor, S., Birhanu, Z., Defar, A., Amenu, K., Dibaba, A., Araraso, D., . . . Hadis, M. (2019). Socio-cultural Beliefs and Practices Influencing Institutional Delivery Service Utilization in Three Communities of Ethiopia: A Qualitative Study. Ethiop J Health Sci, 29(3), 343- 352. doi:10.4314/ejhs.v29i3.6 Abasimi, E., Atindanbila, S., Mwini-Nyaledzibgor, P., Benneh, C. O., & Avane, M. A. 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Japan Journal of Nursing Science, 16(3), 253-262. 143 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Appendix A: Ethical Clearance 144 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Appendix B: introductory Letter 145 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Appendix C: Interview Guide 146 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 147 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Appendix D: Consent Form 148 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES 149 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Appendix E: General Profile Pseudonyms Age Educational Religion Marital Language Current age of background status grandchild (ren) (months) Serwah 50 No formal Muslim Widow Gonja 1month, 2 weeks old years Education Akose 60 No formal Muslim Widow Gonja 2 weeks old (0 month) years Education Konadu 51 No formal Muslim Married Gonja 1 month old years Education Yaa 45 No formal Muslim married Gonja 2 months old Education Owusuah 44 No formal Muslim married Gonja 4 months old years Education Foriwaah 53 No formal Muslim married Gonja 1 month old years Education Adom 48 No formal Muslim married Gonja 2 months old years Education Abena 75 No formal Muslim married Gonja 1 month old years Education Adepa 50 Form three Christian Widow Gonja 6 months old years level Akua 58 No formal Muslim Married Gonja 1 day old (0 month) years Education Asabea 51 Primary Muslim Married Gonja 3 weeks old (0 month) years level Mansah 45 No formal Muslim married Gonja 3 months and 2 weeks years Education old Ama 69 No formal Muslim Widow Gonja 1 month old years Education Adwoa 50 No formal Muslim Widow Gonja 1 month old years Education 150 University of Ghana http://ugspace.ug.edu.gh TRADITIONAL NEWBORN CARE PRACTICES Appendix F: Codes and Descriptions Codes Descriptions ATT Attitudes SBN Subject Norms PBC Perceived Behavioural Control INT Behavioural Intentions BHR Behaviour KD Knowledge AUT Authority 151