A total of 253 individuals from the Kassena-Nankana district in Ghana participated in either in-depth interviews or focus group discussions between July 1 and November 1, 2010. In-depth Interviews were conducted with 35 women with newborn infants, 13 health care providers, 8 traditional birth attendants/herbalists, and 16 community leaders. In addition, focus group discussions were conducted with 81 grandmothers, 22 compound heads, and 78 heads of household. (See Figure .) In this community, ‘grandmothers’ most often referred to mothers-in-law, rather than the mother’s mother. The majority of grandmothers interviewed discussed events that occurred with their son’s wife and children. All women with newborn infants, traditional birth attendants, midwives, and grandmothers were female, however the majority of community leaders, traditional healers, compound heads, and heads of household were male.
Hand washing/glove usage
Hand washing and glove usage during delivery was rarely mentioned spontaneously by respondents.
"“We don’t use bare hands, we use gloves. And then we use clean, sterile gauze and cotton to deliver the woman. So the woman cannot get infection.” – IDI with Kassena midwife"
Health care providers expressed skepticism about the practices of the traditional birth attendants and other untrained providers with regard to hand washing:
"“Maybe the local woman was just washed her hands with water and puts the hands inside to deliver the woman…. With their dirty hands can introduce infection into the woman’s womb, can infect the child, the newborn baby,” – IDI with Kassena healthcare provider"
At least one of the traditional birth attendants described hand washing as important: “The one who is also going to assist her to deliver will wash her hand in a small plastic container and put on your gloves. … We do this because if your skin is having some dirt you can touch the baby with it and if there is any infection the baby will get it.” However, the same traditional birth attendant described using melted shea butter on her hands during pelvic examinations and delivery.
Finally, many women described needing to bring money to pay for soap for nurses to wash their hands if they delivered at a facility. “When she gets to the hospital she has to buy everything like soap so that they can use to wash hands and other things after delivery.” (IDI with women’s group leader) Table illustrates the variability of responses across the groups of respondents.
Representative Quotes from Respondents regarding the Pillars of Clean Delivery and Overarching Themes
Women reported giving birth on a variety of delivery surfaces, including beds with rubber sheets at the hospital, on a mattress or sheet or pile of old rags on the floor at home, in the dirt in the yard, or even on a rock.
"“I gave birth to the baby on a rock (laughing). I was attending to nature’s call (attending to toilet) when I gave birth. We were all sitting outside together when they went inside and let me alone so I decided to go towards the rock to ease myself, it was when I squatted to ease myself that the baby came out.” – IDI with Nankam mother with newborn infant"
Some women indicated that the baby stays where it was delivered until after delivery is complete: “The baby lies in the blood until the placenta comes out, or when (it) is taking too long the cord is cut and baby is bath while the cord tied,” (Women’s group leader) Other women and most health care providers report that the baby is immediately placed with its mother. “Immediately the midwife removes the child, she places the child on the mother’s tummy before the cord will be cut and then all that.” (IDI with healthcare provider (nurse))
Most women appreciated the need for a clean delivery surface as a means of preventing infection in their babies:
"“They have been telling us to deliver in the facilities because they have beds and everything to deliver a woman, but at home you will just deliver on the floor which is very dirty and can make the baby sick,” – IDI with Kassena woman with newborn infant"
"“In the local houses they can deliver a woman in the sand if it becomes critical, but for the nurses, even if it is an emergency they will clean the place before the woman will deliver to avoid the baby from get any infections. The old women, when it becomes critical, they can deliver you in the middle of the road when they do not have anything to spread on the ground for you to deliver on and they have also said such things will give the baby some infections.” – IDI with Nankam woman with newborn infant"
Healthcare providers reiterated the importance of a clean delivery surface: “Oh that is very paramount because, uh, if the environment is not clean, clearly there will be infection. Not only to the woman but also to the newborn. Yes. And clearly we have septicemia as one of the major causes of neonatal mortality here.” – IDI with healthcare provider (physician)
Healthcare providers also indicated that finding a clean delivery surface during home deliveries can be challenging, given the agrarian nature of much of the region: “I am talking about especially in the rural areas, you see the typical compound is around these, um, animal farms. But they also have animals in the yard which are being bred. The animal dung is being collected as manure during the farming season… which is very good. But the problem is, during the dry season or even the rainy season, before you enter the home you have to step on this. And then you get it into the room, more or less infecting the room every now and then. You see. And that is a problem.” – IDI with healthcare provider
Most respondents – including mothers, grandmothers, community leaders, and health care providers – indicated that clinic deliveries were more likely to yield a clean delivery than home deliveries.
Cord cutting and cord tying
Respondents indicated that the umbilical cord was cut within a few minutes of delivery, but exactly who cut the cord varied. (See Table ) Some respondents reported adhering to traditional practices during cord cutting, including covering the mother’s face so she could not see what was happening. “They say it will spoil the eyes of the mother that is why they use the broken calabash to cover their faces before they will cut the umbilical cord.” – IDI with Nankam mother with newborn infant
According to respondents, the cord is typically cut with scissors or a razor blade. Among the 35 recently-delivered women in our sample, 16 women reported the use of scissors, 6 reported the use of a razor, and 13 admitted they didn’t know what was used.
Unprompted, some women described the importance of sterility when cutting the cord: “People are saying that they use contaminated instruments to cut the cord thus infecting it with tetanus, but in the clinic it is not like that so that is why everyone want to deliver in the clinic.” – IDI with Kassena mother with a newborn infant
Respondents indicated a variety of non-sterile tools with which the cords were tied, including rags, twigs, a piece of linen, a piece of string, a small rope, or a plastic clamp. Respondents described the importance of tying the cord to stop bleeding as well as to prevent infection, but local health care providers expressed concerns about traditional practices. “There’s a problem with the home deliveries, they may use all kinds of nonsterile things to cut the cord, or to tie the cord.” – IDI with healthcare provider (physician)
When asked about how the cord was cared for following delivery, community members reported unanimous awareness of the need to treat the cord appropriately. As one grandmother reported,
"“When you are also treating the cord, you have to take good care of it so that dirt will not enter it for it to get rotten and breed maggots because this is where you will not feel comfortable taking care of it.” – FGD with Nankam grandmother"
"“Since there is a sore, if … the one bathing the baby does not blow out the water from the navel after bathing the baby, it will rot. That is why we use shea butter on it to cover the red part.” – FGD with Nankam grandmother"
To prevent excessive moisture and dirt from getting on the cord, mothers and grandmothers report covering the cord with shea butter, ground shea nuts, local herbs, local oil, or “red earth sand.” (See Table ) Another community member described using the juice of a local plant to assist in cord healing.
Health care providers reported that women are advised to put nothing on the cord. One midwife said that she advises women that “if there’s no infection it necroses and then dry off.” Another midwife reiterated:
"“They shouldn’t use anything. Like this local things like cow dungs. That eh, that is the, the olden days. They used the cow dungs to cover the cords. And some use shea butter to cover the cord up. So that can bring, especially cow dung, it can bring infection. Especially tetanus. Neonatal tetanus. And now they don’t do it.” – IDI with healthcare provider (midwife)"
Cleanliness (known as “yeera Kweem” or personal hygiene in Kassem), and maintaining clean surroundings were mentioned in a variety of contexts, including breastfeeding, sleeping quarters, and bathing babies frequently.
Women, grandmothers, and community leaders spoke about the need to keep a woman’s breasts clean prior to breastfeeding an infant:
"“The nurses have taught us that immediately the baby is born and you cut the umbilical cord and the baby cries you have to teach the mother wash her nipples very well. Then you hold the breast into the baby’s mouth.” – FGD with Nankam grandmother"
They also spoke about the need for general cleanliness: “When the woman returns from nature’s call she has to wash her hands before she can pick/carry the baby. If the woman does not wash her hands and picks the baby, the baby can get some infection and become sick.” – FGD with household head
Health care providers also reported that new mothers needed to pay more vigilant attention to cleanliness than other community members:
"“They (young mothers) should be sure every morning they should clean their surroundings, wash their cooking utensils, fetch good drinking water, and then the food they eat, especially the mother if they eat it, clean, cooked food so that she doesn’t get any sickness. And then where the baby is lying should be clean. All the baby’s clothes should be clean. Then they should bathe, the mother and the baby should bathe morning and evening.” – IDI with healthcare provider (nurse)"
Respondents reported that clean sleeping quarters were an important part of preventing infections.
"“After delivery you have to make sure that where the baby is sleeping is clean of dirt so that the baby will not be infected because we know that most of the infections are through dirty places.” FGD with Nankam household head"
"“If the sleeping place is not clean or if you don’t wash it clothes or if you don’t cover it well. It can get cold and fall sick.” – IDI with Kassena woman with newborn infant"
Bathing was mentioned frequently across all types of respondents, the majority of which cited the relationship between frequent baths and reducing the risk of infection.
"“If you cannot keep good hygiene the infections will be there like that. If you do not wash the clothes of the baby and do not dry them if the baby wets them when you wake up in the morning but keep them like that it will give the baby some infections.” – FGD with Nankam grandmother"
Bathing appears to be most often left to the purview of grandmothers. To the question, “Who typically baths the babies?” the response in a focus group of grandmothers was resounding: “We, the ‘kazina’” (Kasem for grandmother) This response was reiterated among women with newborn infants. Out of the 35 women with newborn infants who were interviewed, 24 of them indicated it was their mothers or their husband’s mothers who bathed their babies.
There was general agreement that warm water was used to bathe the babies, but no consensus as to why warm water was used rather than cold water. One Nankam mother’s response was that they “use warm water because the baby’s body is not yet strong.”
Data also suggested inconsistencies with regard to when the babies were bathed. Some mentioned bathing infants shortly after delivery, while others mentioned waiting until later in the day to bathe. None described waiting more than a few hours before bathing.
Data suggested several overarching themes that supersede the six prevention practices. First, the proportion of women in the community who deliver their infants in facilities appears to be increasing. Second, grandmothers have an extremely powerful social position that influences young mother’s behavior. Finally, there appears to be a disconnect between health care providers and the community members in terms of their understanding of ideal and actual maternal and child health behaviors.
Increasing facility based delivery
As one new mother said, “Delivery at clinic and home delivery are not the same because you can deliver safely in the clinic since they have everything there.” (IDI with Nankam mother with newborn) Data indicate that attitudes toward delivering at a facility are changing throughout the community, with grandmothers, community leaders, and compound heads all suggesting that facilities are the safest places for women to deliver. (See Table .)
Another key finding in these data relates to the role of the grandmother in this rural region in Ghana. As was described, grandmothers are frequently in charge of bathing infants. They are also frequently cited as sources of information, decision-makers, and elders who command respect and are in a position of authority.
"“It is the old ladies (that) advice them about where and how to sit to make their delivery easy and how it lies when the pregnancy is about some months.” –FGD with Nankam household head "
In several interviews with women with newborn infants, grandmothers nearby repeatedly engaged in conversation and provided answers for the new mothers, even after being asked to let the women answer themselves. The women interviewed also repeatedly said they would do what their mothers and mother-in-laws told them, because that is how it is done. It was even suggested that the grandmother may have more influence than the baby’s father: “Even though the father can also (give) advice… but that is what we the women do here.” – FGD with Kassena grandmother
Disconnect between providers and the community
Finally, the data collected in this study suggest that health care providers and community members are not always in agreement about what is happening in the community or what is happening in the health care facilities. One example of the disconnect between providers and new mothers in the community relates to what is being put on the umbilical cord. Health care providers unilaterally say that they tell women to put nothing on the cord. Yet more than 70% of the women in our sample said they dressed the cord of their newborn with one of a variety of substances. (See Table ) This example speaks to a broader issue of the relationship between patients and providers in this community. While many patients and providers expressed mutual respect for one another, Table illustrates an example of the language that was repeatedly used to describe the tension between uneducated rural women and the nurses and midwives in the health centers. “Health workers are perceived to be judgmental, so a lot of people stay away…” – IDI with healthcare provider (physician)