Socio-cultural beliefs and practices during pregnancy, child birth, and postnatal period: A qualitative study in Southern Ghana

Abstract

Despite investments in interventions to reduce maternal and neonatal morbidity and mortality, progress has been slow, especially in developing countries. Socio-cultural beliefs in communities often lead to the adoption of certain practices during pregnancy, childbirth, and postnatal period. Therefore, this study was conducted to identify these beliefs and practices and how they affect maternal and child health care services. Purposive sampling was used to select focus group discussion participants (13) among community members, pregnant women whose gestation was at least 6 months, and women with babies less than 6 months of age. In addition, 22 in-depth interviews were conducted among health workers at district, subdistrict, and community levels. All interviews were audio-recorded and transcribed verbatim. With the aid of NVivo 11, the data was analysed thematically. The study’s findings showed that socio-cultural beliefs and practices are widespread covering antenatal through childbirth to the postnatal period. Both harmful and harmless practices were identified. Protecting pregnancy from evil forces resulted in the practice of confinement and consequently late initiation of antenatal care. The use of herbal preparations to augment labour was reported and this practice favoured home delivery and use of Traditional Birth Attendant. The study concludes that socio-cultural beliefs are common and transcend the entire peripartum period. Some of these social practices tend to affect utilisation of some essential maternal and child health practices. However, accepting harmless social practices during labour will improve trust and cater for community’s worldview about childbirth and foster skilled delivery.

Keywords:

• Beliefs
• practices
• antenatal
• labour
• postnatal
• neonatal
• pregnancy
• Ghana

PUBLIC INTEREST STATEMENT

Maternal and neonatal mortality remain a serious public health concern, especially in low resource settings where healthcare facilities and services are not adequate enough to cater for maternal and neonatal cases. Besides, these settings are usually absorbed in socio-cultural beliefs and practices that have been identified to play important roles during pregnancy, childbirth, postpartum period, and care of neonates. Whereas some of these beliefs and practices may be good, others may be harmful. Knowing that these beliefs and practices may differ from community to community, this study used a qualitative research methodology to document beliefs and practices along the prenatal, antenatal, through the peripartum period. This was to ensure that good practices are identified and promoted. In contrast, harmful practices are discouraged in an attempt to reduce the burden of maternal and neonatal mortality in low resource settings, thereby propelling the country towards achieving Sustainable Development Goal 3.

1. Introduction

Maternal and neonatal mortality remain serious problems in low resource settings, where healthcare systems do not meet the minimum standards set by the World Health Organization (WHO; Goldstuck, 2014). The growing recognition of the critical importance of providing care to mothers and newborns and the substantial coverage gaps have prompted a paradigm shift in responding to maternal and newborn health issues. Invariably, the health care that a mother receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and her child.

Globally, about 830 women die from pregnancy- or childbirth-related complications every day and this is unacceptably high (Alkema et al., 2016). In 2015, it was estimated that, approximately 303, 000 women died during and following pregnancy and childbirth in low resource settings, and most could have been prevented (WHO, 2016). In Ghana, data provided by Ghana Health Service at a maternal, child health and nutrition conference in 2021 showed a total number of 875 maternal deaths in 2018 and 838 in 2019. This figure further decreased to 776 in 2020. That notwithstanding, the decline rate is slower than expected (Apanga & Awoonor-Williams, 2018). The primary causes of maternal death are haemorrhage, hypertension, infections, and indirect causes, mostly due to interaction between pre-existing medical conditions and pregnancy. Of the 830 daily maternal deaths, 550 occurred in sub-Saharan Africa and 180 in Southern Asia, compared to 5 in developed countries (WHO, 2016). As at 2015, the risk of a woman in a developing country dying from a maternal-related cause during her lifetime was about 33 times higher compared to a woman living in a developed country (Alkema et al., 2016). It is therefore evident that maternal mortality is a health indicator that shows very wide gaps between the rich and the poor, urban, and rural areas, both between and within countries.

Again, 2.9 million neonates die, with three-quarters of these deaths taking place in the first 7 days of life (UNICEF, 2012). Newborn health also constitutes a human right as specified in the Convention of the Rights of the Child (UNICEF, 2013). The common causes of neonatal mortality include complications of prematurity, infections, and adverse intrapartum events including birth asphyxia and over 60% of the deaths are associated with low birth weight (Debes et al., 2013).

Cultural and traditional practices, values, and beliefs have been identified by Bazzano et al. (2008) to play an important role during pregnancy, childbirth, postpartum period and care of neonates. Socio-cultural practices generally have been reported to affect child survival (Adatara et al., 2019; Wright et al., 2014). By virtue of the fact that communities have their own unique cultures and traditions, maternal and new-born traditional practices may differ from community to community. Good practices need to be identified and promoted whilst harmful practices must be discouraged (Saaka & Iddrisu, 2014). This study was conducted to document the beliefs and practices along the prenatal, antenatal, through the peripartum period among women in Southern Ghana.

2. Methods and materials

2.1. Ethical approval

The protocol for this study was reviewed and approved by Ghana Health Service Ethics Review Committee (GHS-ERC: 006/11/17). All participants signed an informed consent form before participation.

2.2. Study design

This study employed both narrative and phenomenology study designs. Narrative study design allows research participants to share their knowledge on a particular study topic (Bowling, 2014). However, in phenomenological research, the participants’ perceptions, feelings, and lived experiences are paramount and are the object of study (Wertz, 2005). The study relied on the Social Cognitive Theory (SCT) foundations developed by Albert Bandura, a psychologist (Bandura, 2005).

In SCT, learning is viewed as knowledge acquisition through cognitive processing of information. In other words, it acknowledges the social origins of much of human thought and action (what individuals learn by being part of a society), whereas the cognitive portion recognises the influential contribution of thought processes to human motivation, attitudes, and action (Bandura, 1999). The SCT proposes that behaviour change describes a dynamic, ongoing process in which personal factors, environmental factors, and human behaviour exert influence on each other. According to SCT, three main factors affect the likelihood that a person will change health behaviour: (1) Self-efficacy, (2) Goals, and (3) Outcome expectancies. If individuals have a sense of personal agency or self-efficacy, they can change behaviours even when faced with obstacles. If they do not feel that they can exercise control over their health behaviour, they are not motivated to act, or to persist through challenges. As a person adopts new behaviours, it causes changes in both the environment and in the person. In effect, the context in which an individual is, tends to exert some control over the person’s behavioural tendencies. This is on the basis of the social context network model where individuals integrate contextual information during social processes (Ibanez & Manes, 2012).

In adopting SCT, the researchers recognised that socio-cultural beliefs are learnt from the community through a complex, interactive system of physical processes such as observation and modeling (Hammer, 2011). These beliefs lead to practices during and along pregnancy, childbirth, and postpartum periods.

2.3. Study area

This study was conducted in the Asante Akim North District of the Ashanti Region. The Asante Akim North District with its capital Agogo is situated at the eastern part of the Ashanti Region. The district has a population of 69,186 which represents 1.4% of Ashanti Region’s population. The rural areas have a total population of 36,990 representing 53.5% of the population of the District relative to 46.5% residing in urban localities (GSS, 2010). The major ethnic groups/cultures identified are Akan but minority ethnic groups include Fantis, Ewes, Gas, Moshies, Sissalas, Nzemas, Dagombas and Kussasis and Mamprushies. The predominant language is Twi. The various ethnic groups have different cultural beliefs and practices towards prenatal, antenatal, and peripartum periods.

2.4. Selection of study participants

Purposive sampling was employed in selecting participants for this study. Purposive sampling is a non-probabilistic sampling procedure where researchers choose the sample based on who they think are appropriate for the study (Green & Thorogood, 2004). According to Patton (2002), purposive sampling technique is widely used in qualitative research and is appropriate to identify and select information-rich cases for the most effective use of limited resources. In performing sampling activities, the maximum variation form of the purposive sampling was employed to ensure that a wide range of stakeholders was covered to provide a holistic view about the study topic (Andale, 2016). The participants included community members, pregnant women, and women with children under five years.

2.5. Data collection

We used focus group discussions (FGDs) and in-depth interviews (IDIs) for this study. The FGDs were meant to elicit normative ideas on socio-cultural beliefs and practices during pregnancy, childbirth, and postnatal in the community. Eleven (11) FGDs were conducted 5 among males and 6 among female community members. Each group consisted of between 8 and 10 individuals and the participants sat in a horse-shoe fashion with the moderator and rapporteur sitting in the middle. All FGDs were conducted in the community at an agreed time suitable for the participants. Additionally, twenty—two (22) IDIs were conducted among key people in the community such as community health officers, midwives, opinion leaders, traditional birth attendants, and traditional medical practitioners. This was done to get a better understanding of the socio-cultural beliefs and practices among pregnant women in the community.

2.6. Data collection tools and procedure

Semi-structured FGD and IDI guides were used to collect data for this study. FGD guide was developed to solicit information on the socio-cultural practices during pregnancy, preparation for labour, during labour and after delivery. The IDI guide also contained items such as perception of neonatal illness, how health care is sought, and practices. The topic guides were initially designed in English and translated to the local language using a back-to-back strategy. A pilot study was conducted in the Greater Accra region. All the interviews were moderated by the lead author.

During the interviews, detailed descriptive field-notes were written. Generally, field-notes are reported to provide deeper reflection and understanding of experiences in the field (Bowling, 2014). In effect, notes taken during the interviews covered; interactions between the interviewer and interviewees, non-verbal communication, environment, and reflections from interview content. Each of the FGDs lasted between 45 and 60 minutes while each the IDIs lasted for an average of 30 minutes.

2.7. Data analysis

The qualitative data were audio-taped using a digital voice recorder. After each interview session, the recording was replayed to participants to listen and to make the necessary additions, subtractions, and clarifications deemed necessary. As directed by Maynard and Purvis (1994), participants listening to tapes after interviews is an important step in qualitative data analysis even though it is frequently overlooked. The taped interviews were transcribed verbatim into Microsoft word.

Analyses of data occurred concurrently with data collection with the hope of ending the study at the point of saturation, where new data collected no longer brought additional insights. The process included reading and rereading of the interviews and focusing on the identification of themes relating to the beliefs and practices relating to intrapartum and postpartum continuum of care at community. Data collected in local language was first translated into English by two people; the interviewer and another person and the translation were compared for consistency. Any variations in views were discussed and resolved by the translators. The transcripts were imported into NVivo 11 for windows for analysis. Thematic analysis was adopted in analysing the data. Thematic data analysis process consists of three interrelated stages namely data reduction, data display and data conclusion-drawing or verification (Miles & Huberman, 1994). Guest et al. (2012) have also summarised the process of thematic analysis as consisting of reading through textual data, identifying themes in the data, coding those themes, and then interpreting the structure and content of the themes.

A codebook was first developed for the main themes and sub-themes from preliminary reading through the transcripts. The codebook defined the various codes used during coding, their definition, when to use and when not to use such a code and examples of statements that should be considered for coding into particular codes. These codes were turned unto nodes within the software. Following that, line-by-line reading of all transcripts within the NVivo 11 software and relevant portions of statements made by respondents coded unto existing and new nodes. The various codes were analyzed into themes based on the codes to reflect the content of the data collected alongside the writing memos on specific relevant areas. As noted by Creswell et al. (2007), memoing involves putting down initial ideas, issues, observation and patterns that can be connected, compared or contrasted while doing the coding. Queries were also run in NVivo to quantify some of the qualitative data and the results exported and added to the qualitative data in the results.

3. Results

3.1. Socio-demographic characteristics of participants

In all, 94 individuals participated in the study. This was made of 72 and 22 participants in the FGD, and IDI, respectively (Table 1).

Table 1. Socio-demographic characteristics of study participants

SDC	Frequency (n)	Percentage (%)
FGD	N = 72	100
Sex
Male	35	48.6
Female	37	51.4
Educational attainment
No formal education	23	31.9
Primary	21	29.2
Middle/JHS	13	18.1
SHS	11	15.3
Post-secondary/Tertiary	4	5.5
Religion
Christianity	51	70.8
Islam	21	29.2
Ethnicity
Akan	48	66.7
Non-Akan	24	33.3
IDI	N = 22	100
Health workers	13	59.1
Traditional medical Practitioners	5	31.8
Opinion Leaders	4	9.1

3.2. Beliefs and practices during pregnancy

Both FGDs and IDIs showed that it was inappropriate to announce a pregnancy until it becomes visible. It was the general view that people could use their evil to cause an abortion during early pregnancy. As a result, confinement during early pregnancy was a common practice as shown in the quote

Anytime I get pregnant it does not stay, so I was told it is because when you are pregnant and you go out people will look at you with evil eyes to spoil your pregnancy. So this time when I was pregnant I never moved outside the house and I have had successful birth at home (Postnatal woman, IDI).

Further, it was revealed that socio-cultural practices such as not crossing rivers and confinement made some women not show up for ANC. This was especially so for women who lived at places where they had to cross a river to the nearest health facility for ANC. This is illustrated in the following quote:

Some of us live in places where you will have to cross a river before you go the clinic for them to assess you and the baby but because we pregnant women are not supposed to cross the river, we do not go (Elderly woman, IDI).

It emerged during the FGDs that some pregnant women did not take the folic acid they received during pregnancy. This was because of the belief that the drug made their babies big making that results in difficult delivery. This is shown by the quote below:

It [folic acid] gives you appetite for food. When I take all the folic acid given to me at the hospital I give birth to a big baby so this time around I took only half of the medicine because when the babies are big they suffer in coming out during delivery (Postnatal woman, FGD).

Food restrictions were also reported during pregnancy. Participants indicated that ripe plantain and egg were generally prohibited during pregnancy. Ripe plantain for instance, is believed to cause false labour whilst egg is forbidden because of the belief that the baby will become a thief in future. The following quotes illustrate these positions:

before my first delivery they told me not to eat ripe plantain because when you take it you will feel like you are in labour when the time is not even due … we shouldn’t eat eggs else our babies will become thieves and they said if you eat snails saliva will drool from your baby’s mouth, I did all this things but my baby didn’t drool saliva from the mouth (Woman with child under five, FGD).

 … they said if we eat ripe plantain, when you are in labour you push and push but the baby will not come (Woman with child under five, FGD).

when the woman is almost due for delivery she must not eat ripe plantain, it is called “kyem d3” which means that you will be feeling some sweet sensations in your body when you are pushing during pregnancy but the baby will never come out but that practice is now extinct so now we eat the ripe plantain (Elderly woman, FGD)

Some participants also believed that eating of egg during pregnancy was forbidden because it will make the baby’s head soft as illustrated in the quote:

the reason why you are not supposed to eat egg is because if you deliver, your baby’s head becomes very soft, I have tried it and it is true so I had to put a towel in hot water to always massage the baby’s head until about forty days’ time it became good so we stopped (Woman with child under five, FGD).

In addition to the above beliefs during pregnancy, the FGDs revealed some practices in preparation towards labour. Participants mentioned some local herbs that are either ingested or used as enema in preparation towards childbirth. These herbs are extracts from the leaves and bark of some trees in the community, described locally as “awuo mre aduro” meaning medicines that make delivery easy. These herbs make the birth process go smooth without complication. The following illustrate these points

The “Awuo mre aduro” is given to you in the ninth month and it aids smooth delivery (Woman with child under five, FGD).

It is herbs or the back of a tree “nu bena”, you use it to prepare soup and sometimes after delivery the placenta is retained, you use it. You boil it pour it in bucket and sit on it and also drink some (Woman with child under five, FGD).

They normally use some herbs which they add to about seven palm fruits, smoked mudfish and about three fingers of plantain to prepare a particular type of soup called “Abedru” and they start taking it when the pregnancy is about five to six months and they take it till they deliver. It is said that it helps women to have easy and smooth delivery (Elderly woman, FGD).

Another local practice in preparation for labour is engaging in sex. Participants in this study were of the view that engaging in sex during pregnancy was essential in ensuring smooth delivery and highly recommended for women. Some were also of the view that sex restrictions could make one’s partner engage in extra marital affairs. The following quotes support these views:

The husband must have sex with the woman frequently to open up the place so that the woman will have a smooth delivery. The CS is because of lack of sex during pregnancy (Woman with child under five year, FGD).

 … .Having sex with your partner makes delivery safe and smooth and will also prevent your husband from going out to have extra marital affairs (Elderly woman, FGD).

Participants were of the view that baby boys will often lie at the right side of the womb whilst girls lie at the left side. In addition, when one is pregnant with a boy, the uterus is often bigger than when it is a female. Consequently, when women are pregnant and the size of the uterus appears bigger in comparison with the number of months of pregnancy, then it meant that a male child was expected. This was illustrated by the following quotes:

 … .When you are pregnant with a girl there is a place in the womb she sleeps and with a boy too, he has a place he sleeps in the womb (woman with child under five, FGD).

 … when I am pregnant with a boy, he lies on the right side of the womb and girl lies on the left side. For the girl, I vomit a lot but a boy I don’t, it’s only my soles that swell (Woman with child under five, FGD).

What I have noticed is that when I am pregnant with a boy, I have a big stomach but when it is a girl, I have a small stomach (Woman with child under five, FGD).

In addition, participants indicated that swelling of the feet was sign that the baby in the uterus was a male. A participant shared her views as follows:

Males are stubborn, when you are pregnant and the baby is a male, you will often suffer and your feet become swollen and you cannot even walk (Elderly woman, IDI)

There was also the belief that unborn babies can be bewitched by bad or jealous people in the community thus making them develop certain abnormalities in the uterus. This was mentioned and corroborated in the following quotes:

An unborn child can be bewitched by so pregnant women will have to stay at home. It is one of the reasons why people do not go for antenatal in this community (Elderly woman, FGD).

for that one it is like a satanic illness, instead of the baby growing big after forty days, the baby will be growing small, soft body with “Asram” and the fontanelle is not closing up so when you are pregnant you must see those who have these medicines, they will give you herbs to drink and also use to prepare soup so even if someone wants to harm your baby after delivery it won’t work (Woman with child under five, FGD).

3.3. Beliefs and practices during labour

Enema in the form of herbs is given to expectant women during labour as it is believed to facilitate smooth delivery. The herbs are administered to the woman when they are about 5 months into their pregnancy. This is usually the case for women who go to the Traditional Birth Attendant (TBA). The following quotes are illustrations of that practice:

There are herbs we give to pregnant women from five months onwards to help in the birth process. During labour, we also give it the delivery is delaying. It is because of this that some women prefer to come to our facility (TBA, IDI).

The herbs they say makes the baby strong … .we have some we take through the anus, called “Awuo mre aduro”, and for this one they claim it makes you have smooth delivery. We get it from five months of pregnancy (Postnatal woman, FGD).

Some women have preference for giving birth in the squatting position, which is mostly the style prescribed by the TBAs. It is for that reason that a participant indicated the choice for people to utilise the TBA outlets. This is illustrated in the quote:

We prefer to give birth in squatting position because it makes it easy for the baby to come out. That is the reason why I delivered at the TBA’s place. In the hospital they make you lie down and raise your leg. For my first born, it was so difficult when I delivered in the hospital (Postnatal woman, FGD).

3.4. Beliefs and practices during puerperium

The beliefs and practices during puerperium were further divided into those that are related to care of the baby and those related to the mother.

3.4.1. Beliefs and practices on baby

In all the interviews, participants were of the view that a baby had to be confined until the official outdooring and naming was done. This according to participants was to protect the baby from evil people in the community. For example, a pregnant woman quoted:

Some jealous people can bewitch and kill your baby. So, you have to keep the baby in the room until outdooring where they would have performed the rituals to protect the baby (Pregnant woman)

As a result of this belief neonatal conditions had to managed at home because attendance to the hospital during that period was believed to create the opportunity for the baby to be bewitched. A participant shared her experience with the quote:

When I gave birth, my baby was not well but we managed the condition at home … I was afraid sending the baby to the hospital would expose her to witches in the community (Woman with child under five)

Some participants were of the view that yellowish discoloration of the eyes and palms of the baby are normal and will often resolve with time. The following quotes illustrate some participants view about this:

When you give birth to the baby and the eyes and palms are yellow, it is normal because of the change in the environment of baby. This will often go away so we do not seek medical attention for it (Elderly woman, FGD).

The yellow babies” is something that happens. You expose the baby to the sun and it will disappear. I also have some medicine that I apply on the baby’s body for it to disappear (TBA, IDI).

Regarding cord care, it emerged from the study that it was a common practice to dress the cord of the baby and smear it with shea butter. This practice was believed to offer protection against infection and keep the cord dry. During bathing of the baby, the head is massaged and molded. This practice was believed to contribute to making the head round as illustrated with the quotes:

We prepare both hot and cold water for the bathing of the baby and then we use shea butter to massage their whole body and then we use cool water to massage their heads (Elderly woman, FGD).

She measures the cord with her hand and then she will tie it and cut it with the blade. They use uncooked cocoyam and they make a hole in it and they put water and salt in the hole they’ve made, they put the water on the cord and within three days it will come off (Woman with child under five, FGD).

The study participants indicated they have received education on the need to exclusively breastfeed the baby for 6 months. However, majority of them reported that they do not adhere to this practice due to several reasons. Some participants for instance, were of the view that the breastmilk was inadequate for the baby, hence there was the need to give other food supplements such as mashed kenkey and artificial milk sources. Another reason cited was the belief that babies get thirsty with time and therefore, there was the need to provide them with water. They were of the view that babies need variety in their diet. Consequently, there was the need to introduce them to other foods instead of breastmilk only. The following quotes reflect these views:

I give them food, starting from the fourth month because my breast milk is small. Sometimes I mash kenkey, sieve it and add lactogen to it (Postnatal woman, FGD).

We as adults do not eat only one food. We take fufu, banku and rice but we expect our babies to be eating breastmilk that is not fair. So, we have to give them soft food after some week (Elderly woman, FGD).

I tried to practice exclusive breastfeeding but at a point in time the weather was too hot and as adult we sweat and feel thirty. So, my baby also started feeling thirsty and will be crying uncontrollably. So, my mother advised me to give him water and he stopped. Since then I have been giving him water and some mashed kenkey (Postnatal woman, FGD).

The belief among participants was that female babies were born with sores in their vulva which needed to be treated with warm dressing to help in the healing process. To address this problem, they indicated that during bathing for the babies, they apply warm compresses on the fontanelle and genitalia of female babies. Doing so was believed to aid in the closing of the fontanelle, as well as facilitate the healing of sores in the vulva of female babies. The following quote buttresses this assertion by participants:

I put towel in hot water and put it the baby’s fontanelle then I use the hot water to douche the baby’s navel, private part and buttocks. I put hot water compresses on the fontanelle because it is soft and so when I do that it helps to make it strong and also close the gap in the fontanelle. We douche the children because when you give birth to baby girl they normally have sores in their private parts (Postnatal woman, FGD).

Additionally, babies are massaged with mustard oil and shea butter. This practice was believed to make the baby healthy and also prevent the skin from becoming “dried up” as illustrated with the quote:

We massage the baby with mustard oil or shea butter to make the baby healthy and prevent drying up of the skin (Postnatal woman, IDI).

3.5. Beliefs and practices on mother

Participants in this study revealed some socio-cultural practices that were observed for women after child birth. These practices were often aimed at restoring the mother to pre-gestation state and also facilitate the growth of the baby. For example, the belief was that women developed internal wounds after delivery. As a form of treatment for the wounds, herbs extracted from the bark of a tree “nu bena” was given to the women to enhance healing of the internal wound. The following quotes are illustrations of that belief:

When a woman gives birth, she develops a wound which will have to be treated. So we give the woman the herbs to drink to help in the healing of the wound. If this is not treated, it can affect the woman’s health and that of the child (Postnatal woman, FGD).

After delivery, they go for some herbs to prepare “Abedru” so that the breast milk will come (Woman with baby under five years, FGD).

 … when you go to the women who sell medicine in the room and you explain to them what you are going through, they can get you some herbs to cook and drink. Some help to heal wounds in your stomach after birth (Postnatal woman, FGD).

Participants in the FGDs mentioned food restriction during the period of puerperium. According to them, certain foods were believed to decrease the production of breastmilk and also cause stomach-ache. Some of the foods mentioned were included ripped plantain, okra and oranges. Okra for instance, was also believed to cause diarrhoea for breastfeeding babies. It was therefore not advisable to eat it during that period. The quotes below reflect this belief:

When we deliver, we don’t eat orange because of the wounds we get after birth and it also drains the breast milk … . and ripe plantain too, that one when you eat it, it makes you defecate frequently. As for okro, it will make the baby have diarrhoea (Woman with under- five child, FGD).

Ripped plantain cause stomach pains and hence women who have delivered are prohibited from eating it (Postnatal woman, FGD).

In relation to sexual practices after birth, participants generally agreed that the practice could vary among couples. Whereas some indicated that sexual intercourse could begin 40 days after delivery, many of them noted they started having sex 3 months after delivery. However, the unanimous position was that sex activity could start at least 40 days after delivery. These positions are shown with the following quotes:

It depends on every individual; I sometimes indulge in sex six months after delivery (Postnatal woman, FGD).

You will have to wait for at least forty days before having sex or sometimes for three to six months after birth (Elderly woman, FGD).

That notwithstanding, participants also agreed that generally, there was the need for one to space the children. One must therefore protect herself against unplanned pregnancy. There was, however, no consensus on the strategies used to prevent unplanned pregnancy. While some participants mentioned their use of modern contraceptive methods, others preferred the natural family planning methods as illustrated with the quotes below:

What I see is if the man wants to sleep with you and you don’t use any medicine you can easily give birth even if you have a small baby already. For me I have a small baby so I protect myself using the injectable so that I don’t get pregnant (Woman with children under five, FGD).

I do not like the family planning method we get from the hospital. I have natural way of protecting myself or I use some herbs we have the community. They are also good in protecting women against pregnancy (Postnatal woman, FGD).

Some FGD participants were of the view that the modern contraceptive methods could render a woman barren and therefore preferred to use natural methods. The view held by some participants was that using modern contraceptive method will make it difficult for the woman to conceive after she has stopped using it. The following quotes are reflections of those views:

Sometimes when you go for them and you later on decide to give birth and want to take it out, it can break your womb and render you barren (Woman with under five child, FGD).

We are very fertile here so we all have children and if anyone is not having a child then it is probably the kind of life she had lived and the family planning too if you use it, it can destroy your womb because when you use it for a long period of time, it remains in your blood and it will take long to for it to leave your system for you to get pregnant again (Woman with child under five, FGD).

4. Discussion

Pregnancy, child birth, and care are cherished moments in most communities in Ghana. However, certain beliefs tend to make these moments also prone to certain rituals and concealment, all in an attempt to ensure that there is no mishap during any of these periods. In view of that, there are certain socio-cultural beliefs and practices that are supposed to buffer any untoward occurrence. However, it turns out, that in as much as some of these beliefs and practices are helpful, some can be detrimental to both mother and child.

4.1. Beliefs and practices during pregnancy

The fear of losing pregnancy as a result of bewitchment made pregnant women resort to the practice of confinement, which has implication for the early initiation of antenatal care. Members of Nuaulu tribe of Indonesia for example, are noted to have a “high perception” towards practice of pregnancy in seclusion. They interpret this as good practice that is beneficial to them in some way or another. A study conducted in Zambia found out that women intentionally delayed the initiation of Ante Natal Care (ANC) to avoid making several visits to the healthcare facility and to reduce the overall costs of patronising the facilities (Menon et al., 2010). In this study, the socio-cultural practice of confinement rather delayed the initiation of ANC. The ANC schedule is programmed such that a pregnant woman will have to make monthly visits during the first 7 months. In the eighth month, two visits are to be done and then weekly visits during the final month, culminating in 12–13 visits overall. However, the practice of confinement does not make women start ANC early enough to enable them meet the required number of visits during pregnancy.

Essential health services such as monitoring the growth of the baby in utero, giving tetanus injection and the administering of Suphadoxine-pyrimethamine (SP) to help reduce malaria during pregnancy are provided during ANC. Hence a woman starting the ANC late may not be able to complete these services as required. For example, every pregnant woman is expected to take at least 8 doses of the prophylaxis as per the new World Health Organization (WHO) recommendation (WHO, 2019). There is therefore the need for healthcare providers to highlight these socio-cultural practices during health education and also design interventions targeted at reaching those who may be confined at home. This is crucial if Ghana is to achieve universal health coverage and access to essential perinatal care as envisioned in the Sustainable Development Goals (SDGs).

4.2. Beliefs and practices during labour

The findings of this study that the use of herbs during labour to facilitate the process was a common practice among women. This practice which would not be accepted in the healthcare system was thus a barrier to the formal facility delivery unlike home delivery where it is accepted. For some people, herbs were good for smooth labour and hence women would rather go to places where the use of herb is acceptable. Consequently, home delivery or using a Traditional Birth Attendant (TBA) who are receptive to the use of herbs becomes the preferred choice. A study in Ghana found that pregnant women were given herbal medicines by traditional birth attendants to induce labour, augment and control bleeding during labour (Otoo et al., 2015). Unfortunately, herbal remedies which are regarded to promote healthy delivery have been found to lead to severe bleeding that can be fatal according to a study in Bangladesh (Choudhury & Ahmed, 2011). These herbs are used at places where there is less expertise in managing antepartum and postpartum haemorrhage. Postpartum haemorrhage for instance, is one of the leading causes of maternal deaths in Ghana and most of these deaths have occurred due to delays in referral or seeking health care.

Women’s maternal health choices during pregnancy and delivery directly influence maternal and neonatal morbidity and mortality (Evans, 2013). The process of pregnancy and childbirth is permeated with strong cultural practices and traditional beliefs that impact maternal healthcare utilisation (Houweling et al., 2007; Rice, 2000). Other practices that place mothers at risk of disability or death include applying fundal pressure to hasten the labour process, forced vomiting to initiate the placenta expulsion, use of herbal concoctions for treating maternal complications and childbirth in an isolated or unsanitary environment (Fofie & Baffoe, 2010; Maimbolwa et al., 2003). In several cases, the lack of knowledge of the underlying physiology of pregnancy also contributes to cultural definitions of pregnancy-related symptoms, and thus leads to inaction (Evans, 2013). Studies in Ghana and Nigeria have documented that pregnant women in these countries saw pedal oedema as a sign that a male child or twins will be born, and were not able to make the connection between the oedema and high blood pressure (Okafor et al., 2014; Senah, 2003).

The study found that some mothers prefer to give birth at facilities of traditional birth attendants. The study found squatting position is one of the reasons for the use of TBA facilities. However, babies born at such places may miss out on immunisations given immediately after birth like BCG and OPV. There is therefore the need for the formal health system to collaborate with the TBAs to ensure all such babies are immunised. Community Health Officers who are currently responsible for implementing CHPS strategies can regularly visit TBA facilities to provide immunisation and other essential newborn care services. The CHPS concept is designed to provide door-to-door care (Nyonator et al., 2005; Pence et al., 2007), and has been found to improve provision of maternal and child healthcare services (Nyonator et al., 2005).

Training of Traditional Birth Attendants (TBAs) and providing them with disposable delivery kits was the focus of a study carried out in Pakistan where the intervention arm of the study recorded less maternal deaths than the control arm, and a 30% decrease in neonatal mortality (Jokhio et al., 2005). Another reason cited for delivery at TBA is the use of herbs which is believed to be effective and facilitate the labour. As found in some studies, women’s preference for TBAs during pregnancy and labour, compared to the healthcare facilities was due to the use of herbal medications, which was preferred to the drugs and vaccines administered at the ANC clinics (Okafor et al., 2014). In the light of these, health education offered to women during ANC visits should highlight the necessity for the continuum of care that includes skilled attendance at birth and postnatal care.

4.3. Beliefs and practices during postnatal period

Neonates are perceived to be vulnerable to the “evil eyes” of jealous community members. Some measures are therefore taken to protect the neonate against any such thing in the community. As a result, neonate and mother are confined for periods ranging from 1 week to about 40 days. During this period, the baby is not allowed to either be seen or touched by people who are outside the nuclear family. This social practice restricts the mother and the neonate from seeking health care outside the home thus preventing the continuum of care during the neonatal period. In Bangladesh, an earlier study reported that confinement of the mother and baby was observed until “noai” ceremony on day 7 or 9 to protect the baby against any evil (Winch et al., 2005).

This practice needs to be given much attention as majority of the practices that predispose babies to severe morbidities and even mortalities are still occurring (Lawn et al., 2014). Data from the WHO show that preterm birth accounts for 30% of the global neonatal deaths, sepsis, or pneumonia for 27%, birth asphyxia for 23%, congenital abnormality for 6%, neonatal tetanus for 4%, diarrhoea for 3%, and other causes for 7% of all neonatal deaths. These conditions become fatal during the first week of life and require prompt attention. However, neonates with these conditions may not have access to good medical care because of the mandatory confinement as a way of protecting the baby against evil eyes”. In their study in Bangladesh, it was found that 37% of the neonatal deaths occurred within 24 hours, 76% within 0–3 days, 84% within 0–7 days, and the remaining 16% within 8–28 days (Chowdhury et al., 2010). Intensifying community-based home visit by health worker has the potential to identify such conditions and offer medical advice. Community-based management of neonatal conditions using trained village health workers has been shown to be effective in reducing neonatal mortality (Bhutta et al., 2005).

4.4. Conclusion

Socio-cultural beliefs are common and transcend the entire peripartum period. These beliefs lead to the adoption of certain practices, most of which have negative effects on mother and baby. These social practices tend to affect utilisation of some essential maternal and child health practices. The acceptance of harmless social practices during labour however, will improve trust and cater for community’s worldview about childbirth and ultimately foster skilled delivery.

Author’s contributions

JA designed the study, participated in data collection and analysis, and prepared the draft of the manuscript; EA and PBA provided scientific advice on the design of the study and data analysis. All authors read and approved the final manuscript

Data availability

Majority of the anonymised data have been included in this manuscript. Providing the individual transcripts will breech the confidentiality and anonymity requirement during ethical approval. As a result, we do not have permission from the participants to share the raw data. All interested researchers/readers/persons who meet the criteria for access to confidential data can access the data set from the corresponding author via this email address: [email protected]

Acknowledgements

The authors wish to thank all study participants for their time.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The authors solely funded this study.

Notes on contributors

Emmanuel Asampong

Dr. Joana Ansong, a Programme Officer at the WHO, Ghana Country Office is responsible for health promotion. Her research interests are in social, behavior and cultural dynamics affecting maternal, neonatal and child health as well as Non-Communicable Diseases. Her research focuses on bringing to the fore socio-cultural practices influencing intra-partum and post-partum continuum of care and how these serve as social drivers in health seeking behaviours for mothers and neonates as well as health outcomes. This current study sought to characterise the critical role of traditional birth attendants in communities and determine a more comprehensive and systematic approach of strengthening collaboration between the orthodox and non-orthodox delivery of health services especially at the community level. This project aims to reduce maternal and neonatal morbidity and mortality burden and accelerate Ghana’s quest to achieve Sustainable Development Goal 3.