Giving Birth: The Voices of Ghanaian Women

UHCW_A_434563

702xml

January 4, 2010

22:32

UHCW #434563, VOL 31, ISS 3

Giving Birth: The Voices of Ghanaian Women Stephen Eugene Wilkinson and Lynn Clark Callister

QUERY SHEET This page lists questions we have about your paper. The numbers displayed at left can be found in the text of the paper for reference. In addition, please review your paper as a whole for correctness.

Q1. Q2. Q3. Q4. Q5. Q6. Q7. Q8. Q9. Q10. Q11. Q12.

Au: Location of Creighton? Au: Page no.? (Maimbolwa et al.) p. 274 as meant? Au: Author name? (UK, 2006) Au: Create reference for web address? Au: Please give quote attributions. Au: Placement of quotes “Do this” ok? Au: Insert Table 1 call out in text. Au: Year of UNICEF reference? 2006? Or provide 2008 reference. Au: Pages of Biritwum, 2006. Au: Page nos.? (Callister & Khalaf, 2009) Au: First initials? (Grace & Powers, 2009) Au: Author of United Kingdom, 2006? What agency released these statistics ? Q13. Au: Publisher? Location? (Zuzelo, 2007)

TABLE OF CONTENTS LISTING The table of contents for the journal will list your paper exactly as it appears below: Giving Birth: The Voices of Ghanaian Women Stephen Eugene Wilkinson and Lynn Clark Callister

0

UHCW_A_434563

702xml

January 4, 2010

22:32

Health Care for Women International, 31:1–20, 2010 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399330903343858

1

Q1

2 3

Giving Birth: The Voices of Ghanaian Women STEPHEN EUGENE WILKINSON Creighton University School of Medicine

LYNN CLARK CALLISTER

4 5

Brigham Young University College of Nursing, Provo, Utah, USA

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Childbirth is significantly influenced by women’s cultural perceptions, beliefs, expectations, fears, and cultural practices. Our purpose in conducting this focused ethnography was to determine the perceptions of Ghanaian childbearing women. Twenty-four mothers who received health care at the Salvation Army Clinic in Wiamoase, Ashanti, Ghana, participated in audiotaped interviews. Patterns of thought and behaviors were analyzed, describing the realities of the lives of Ghanaian childbearing women. Themes included centering on motherhood, accessing health care, using biomedicine, ethnomedicine, and spiritual cures; viewing childbirth as a dangerous passage; experiencing the pain of childbirth; and fearing the influence of witchcraft on birth outcomes. Culturally specific knowledge obtained in this study can be utilized by health care providers, health policymakers, and those designing health care interventions to improve the health and wellbeing of childbearing women in developing countries.

23 24 25 26 27 28

Cultural competence is a vital component of quality health care delivery. Key reasons for the heightened focus on providing culturally competent care include increased migration, increased retention of cultural/ethnic identity, use of highly technological health care that may clash with cultural values, and an increased propensity for litigation related to linguistic challenges and cultural conflicts (Andrews & Boyle, 2008). Received 7 July 2008; accepted 27 April 2009. Funding is provided from Brigham Young University Office of Research and Creative Works, Kennedy Center for International Studies, and Phi Kappa Phi. We express our appreciation to the women who participated in the study. Address correspondence to Dr. Lynn Clark Callister, 136 SWKT, Brigham Young University, Provo, UT 84602, USA. E-mail: lynn [email protected] 1

UHCW_A_434563

2

Q2

Q3

702xml

January 4, 2010

22:32

S. E. Wilkinson and L. C. Callister

29 30 31 32 33 34 35 36 37 38 39 40 41

The British medical journal, The Lancet, headlined in the September 2006 issue: “[Women’s] voices need to be heard by decision-makers” (Rosato et al., 2006, p. 1187). Listening to the voices of women is vital because it leads to improvement of services for childbearing women and their families, promoting the delivery of culturally sensitive quality health care. Qualitative research can be utilized to answer questions about the meaning of life experiences, promoting evidence-based practice (Grace & Powers, 2009). Our purpose in this focused ethnography was to describe the perceptions of childbirth among Ghanaian women. Findings can be utilized to inform health policymakers and health care providers on the perceptions of Ghanaian childbearing women in order to ensure that health care is “clinically safe and culturally sensitive” (Maimbolwa, Yamba, Diwan, & RansjoArvidson, 2003, p. 74).

42

BACKGROUND

43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68

More than 50,000 Ghanaians immigrated to the United States between 1997 and 2006 (United States Department of Homeland Security, 2007), while more than 26,000 Ghanaians immigrated to the United Kingdom during the same time period (UK, 2006). These immigrants bring with them their cultural beliefs, attitudes, and practices. With a heightened emphasis on cultural competency in health care, there has been an increase in the literature focusing on the meaning of childbirth to culturally diverse women (Callister & Khalaf, 2009). While research has been done with West African childbearing women (D’Ambruoso, Abbey, & Hussein, 2005; Jansen, 2006), however, no known published research specifically has examined the meaning of childbirth to Ghanian childbearing women. Agovi (2003) found that religious Ghanaian women share a sense of rich spiritual significance in having a child and that childbearing is a key element in social respect and hierarchy. Agovi concluded that further research is needed for a comprehensive understanding of Ghanaian women’s perspectives of childbirth. Sixty-nine percent of Ghanaians are Christian, 16% are Muslim, and 15% practice traditional or other religions (United States Department of State, 2007). Spirituality plays a major role in Ashanti culture, and traditional beliefs often overlap both Christian and Muslim beliefs and practices (Akrong, 2000). The services of okomfos (fetish priests), for example, often are employed by Christians, Muslims, and traditionalists to cure physical and social ailments that are believed to have supernatural origins. In Ghana, becoming pregnant creates ambivalence. According to AmohAgyei,

UHCW_A_434563

702xml

January 4, 2010

22:32

Ghanaian Perceptions of Childbirth 69 70 71 72 73

74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94

3

Pregnancy should be a time of expectation and joy for a woman, her family, and the community. For most women in Ghana, the reality of expectant motherhood is often grim due to unforeseen complications of pregnancies and childbirth, which sometimes lead to death. This is of great concern to the whole nation. (2004, p. 42),

Another researcher wrote, “Traditional ideas about pregnancy and childbirth tend to have health implications on pregnant women. In the rural context, child bearing is still one of the most dangerous moments in a woman’s life” (Dauda, 2005, p. 35). Ninety percent of Ghanaian women have at least one prenatal visit, with 69% having four or more visits. Fifty-three percent of births are not attended by skilled personnel. The birth rate is 32 per 1,000 population, the perinatal mortality rate is 34 per 1,000, and the infant mortality rate 68 per 1,000 live births. The maternal mortality rate is 540/100,000 live births, with a lifetime risk of maternal death of 1 in 35. The life expectancy for women is 58 years. (United Nations International Children’s Emergency Fund [UNICEF], 2006). Q4 It should be noted that there is no adequate vital registration systems, and government estimates differ from WHO/UNICEF/UNFPA estimates (Callister, 2007). In accordance with the World Health Organization’s (WHO’s) Safe Motherhood Initiative program to help lower maternal mortality rates, the Ghanaian government provides four prenatal visits without charge (Biritwum, 2006). The Ghanaian government, in conjunction with the United States Agency for International Development (USAID), UNICEF, and the United Nations Population Fund promote certification of traditional birth attendants (TBAs) who attend home births.

95

CONCEPTUAL FRAMEWORK

96 97 98 99

The theoretical perspectives of the Health Belief Model include important constructs of beliefs, attitudes, values, and actions for understanding health behavior (Stretcher & Rosenstock, 1997). This framework can be utilized to guide clinical practice, clinical research, and health policy.

100

RESEARCH METHODS

101

Design

102 103 104 105 106

A focused ethnographic approach was used, with intensive participant observation of Ghanaian childbearing women in the clinic and villages. The principal investigator listened to the voices of the women and other key informants such as Ghanaian health care providers in order to become immersed in the culture (Speziale & Carpenter, 2007; Spradley & McCurdy, 1972).

UHCW_A_434563

702xml

4

January 4, 2010

22:32


107

Setting

108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149

This study was conducted in Wiamoase and surrounding villages in the Afigya Sekyre District of the Ashanti Region in south-central Ghana, primarily in the Salvation Army Clinic (SAC). The principal investigator was a participant observer as a clinic volunteer, participating fully in the ongoing activities in the clinic and villages. In this district in 2006, only 55.5% of births were attended by skilled professionals (Ghana Health Services, 2007). There were 411 births at the clinic in 2006. The SAC has a staff of 32 health care workers, including one certified midwife, nurses, and a number of TBAs. In addition to the maternity ward, the clinic also has a pharmacy, a weekly opthamology clinic, a weekly pediatric clinic, a weekly postnatal clinic, and three weekly antenatal clinics (ANCs). Three outreach clinics a month serve villages and hamlets that lack health care services. The SAC begins work each day with a Christian devotional including prayer, though some of the staff espouse the Islamic faith. The ANC is held in an open air building. Cement benches line the walls and the mothers arrive throughout the morning, many bringing their small children with them. The clinic becomes an informal social support network with women sharing advice. Mothers are given a maternal health record book provided by Ghana’s Ministry of Health and the WHO. This document is kept by the mothers, who bring their personal health records with them when they are in active labor. Labor and birth records are kept, which is useful if a woman is referred to another health care facility due to complications. During pregnancy, each mother is given a list of supplies that she should bring with her when she comes to give birth. For example, women are asked to bring pads, surgical gloves, a lidded plastic bucket, disinfectant, and maternal and infant care needs. Only 15.5% of pregnant women in Wiamoase visit the prenatal clinic more than four times during their pregnancy (Ghana Health Services, 2007). Many multiparous women do not seek care until the second or third trimester, since pregnancy is considered a healthy state not requiring medical management. In the clinic, women are examined by the midwife. Monthly visits are encouraged through 28 weeks gestation, then every 2 weeks, then weekly for the last month. Mothers are given calcium with each checkup at a cost of 20 pesewa (approximately U.S. $.20). They are also given multivitamins, iron, and folic acid for fifty pesewa (approximately U.S. $.50). Expectant mothers receive two doses of a tetanus vaccine. A mobile ultrasound scanner is used for one scan during pregnancy at a cost of six Ghana cedi (approximately U.S. $6). Blood work, including hematocrit and blood typing as well as testing for HIV/AIDS and malaria, is conducted. Group health education is provided, with topics including cleanliness, nutrition, infections such as malaria, danger signs to be aware of, and the importance of praying for a successful birth. Malnutrition is a prevalent challenge in rural Ghana,

UHCW_A_434563

702xml

January 4, 2010

22:32

Ghanaian Perceptions of Childbirth 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192

5

with slightly more than 10% of children born at the SAC weighing less than 2.5 kilograms (5.52 pounds; Wiamoase Salvation Army Clinic, 2007), so the “health talk” on maternal and infant nutrition is particularly important. Giving birth at the SAC, including a 3-day stay, costs ten Ghana cedi (approximately ten U.S. $10). Cesarean births are done at a hospital in near Asamong or Mampong, which costs several hundred U.S. dollars. Women are encouraged to put aside financial reserves in case of such an emergency. A laboring woman may be driven in the clinic’s “ambulance” (a Land Rover) to the Asamong hospital, a 20–25 minute drive, only to find there is no physician on duty. If this is the case, the mother is rushed to the Mampong District Hospital, where the probability of a surgeon being present is much higher. This adds an additional 30 minutes of travel time, which may have adverse consequences in an emergent situation. There are two birthing rooms at the SAC, and in the case of more than two women giving birth simultaneously, an examination room also may be used. The beds are flat and do not incline. The clinic has no running water, so rain water is collected and stored in wells and storage barrels. In the primary birthing room there is a gas stove on which the staff boils water. In the primary birthing room there is also an autoclave used to sterilize instruments. Pitocin, surgical gloves, saline, intravenous needles, tubing, and other supplies are available. Ghana has frequent power blackouts, and if the power is off at night when a mother was giving birth, kerosene lamps are used to illuminate the room. As part of observational data, the primary investigator attended 10 births with the consent of each mother to gain a sense of customary practices at the clinic. Although no analgesia/anesthesia was used during the labor and birth, very few of the women cried out as they gave birth. Some mothers prayed vocally, calling upon God to protect them and grant them a safe birth. One woman called out, “See what God has done!” immediately following giving birth. Oxytocin was used with almost every birth, both to induce and augment labor and to control postpartum hemorrhage. Many of the women were physically exhausted, having worked in the fields while in active labor, and travel to the clinic from outlying areas sometimes rendered the mother very fatigued. Stories were told of women who gave birth alone at their farms, cutting the umbilical cord with their machete. No support persons, other than the staff, were present during the labor or birth. Only one of the mothers observed had laughed and smiled with joy after giving birth. The mothers rest for 10–40 minutes, dress, and walk, at times unassisted, down a 20-foot hall to the recovery room. The mother and baby were separated between 30 and 75 minutes, and then the newborn was placed on the bed next to the mother. In most cases, the mothers did not touch their infant immediately, but eventually they breastfed. There are six

UHCW_A_434563

702xml

January 4, 2010

6

22:32


193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217

beds in the maternity ward, and women stayed for up to 3 days. Mothers with complications stayed longer. Newborns were cleaned, weighed, and dressed while the mother rested. Female family members were allowed to see the mother after the birth. Most family members focused their attention primarily on the mother, only momentarily glancing at the newborn if at all. To prevent the newborns from contracting malaria, each bed in the clinic room had a net, and the mothers were expected to use them. Bed nets occasionally are donated to the clinic to be distributed to mothers with newborns (Fegan, Noor, Akhwale, Cousens, & Snow, 2007). Only 27% of Ghanaian children under the age of 5 sleep under an insecticide-treated bed net (Noor, Mutheu, Tatem, Hay, & Snow, 2009). It is important for women to show that they properly care for their children by bringing them to the clinic monthly and documenting appropriate weight gain. It is believed that those who have small infants have not been breastfeeding them properly, and the women have fears of being insulted. If a child is malnourished, the mother and child are referred for a 3-week stay in the clinic’s malnutrition unit where protein-rich food is provided for the child and the mother is taught how to prepare simple, high-protein meals. Unfortunately, the desire to have large children both to impress others and prevent being referred to the malnutrition unit leads some women to give their young infants corn porridge (Gyimah, 2006). A traditional medicine known as shelea, a chalk-like substance, is put on the child’s skin wherever the mother wants the child to “become big.” The 40-day weighing in symbolizes the end of the postpartum period, a rite of passage or the official beginning of motherhood.

218

Conduct of the Study

219 220 221 222 223 224 225 226 227 228 229 230 231 232 233

Following institutional review board approval, we invited 24 women who attended the SAC prenatal clinic to participate in the study. Snowball sampling was done to recruit study participants from surrounding villages. These women were interviewed during outreach clinic days. Prior to being interviewed, each study participant completed consent forms. In cases where the potential participants were sub- or illiterate, these documents were read aloud and explained to them. In cases where they were unable to sign the consent form, a fingerprint was taken in accordance with Ghanaian law. Thick descriptions were kept of the interviews as well as the clinic and village settings. Data analysis and verification of categories or themes proceeded concurrently with data collection as appropriate for ethnographic inquiry (Spradley & McCurdy, 1972). Interviews were conducted by translators with the principal investigator, and audiotapes were transcribed and translated. The researcher was the instrument, accessing data from an etic perspective. The researcher was sensitive to not leaving a “research

UHCW_A_434563

702xml

January 4, 2010

22:32

Ghanaian Perceptions of Childbirth

7

234 235 236 237 238 239 240 241 242 243 244 245

footprint” and focused on reflecting the perspectives of the informants (Mitchell & Irvine, 2008). Preliminary analyses of the transcriptions were performed separately by members of the research team, and then in collaboration to identify analytic codes. Member checks were done with five mothers who were interviewed a second time. These secondary interviews validated the previously identified themes that described the realities of the lives and perspectives of Ghanaian childbearing women. Field notes were used to record observations, impressions, and insights. A comparison of content analysis of interview and observational data was conducted to enhance the quality of the findings (Roper & Shapira, 2000). Narrative data are used as follows to illustrate the themes, with themes compared with findings in the literature.

246

FINDINGS

247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274

Among the 24 study informants, maternal age ranged from 18 to 42 years, with a mean of 26.2 years. Twenty were married, three unmarried, and one was separated from her significant other. None of the mothers had completed secondary school. Eight were farmers, seven were homemakers, four were hair stylists, four were petty traders (small business women), and one was a seamstress apprentice. The number of pregnancies ranged from one to 12, with a mean of 3.92. The number of living children ranged from one to 10, with a mean of 3.46 children. Two previously had aborted pregnancies and six had experienced neonatal losses. The first prenatal visit ranged from 4 to 36 weeks gestation, with a mean time of first visit of 24 weeks. The number of visits ranged from three to 18, with a mean of 7.5 visits to the clinic. All of the study participants said the pregnancies were unintended. Ten of the women gave birth at SAC, two had Cesarean births at the hospital (one set of twins), 11 gave birth at home, and three gave birth precipitously on the way to the clinic. With the exception of those having Cesarean births, the women received no analgesia/anesthesia for childbirth. Length of labor ranged from 30 minutes to 26 hours, with a mean of 11.8 hours. The mothers had given birth between 2 weeks and 14 months prior to being interviewed. Audiotaped interviews lasting 30–60 minutes were conducted privately. Informants were compensated for their participation in the study with a newborn kit with soap, cloth diapers with safety pins, socks, a blanket, and a layette gown. The mothers’ sincere gratitude for such a simple gift was touching. The mothers who allowed their childbirth to be observed also were given a quilt for their newborn. Themes included centering on motherhood, accessing health care: the use of biomedicine, ethnomedicine, and spiritual cures; viewing childbirth as a dangerous passage, experiencing the pain of childbirth, and fearing the influence of witchcraft on birth outcomes.

UHCW_A_434563

8

Q5

702xml

January 4, 2010

22:32


275

Centering on Motherhood

276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291

Motherhood is a primary role for Ghanaian women. Proven fertility is essential: “If you are not married, and you don’t give birth, nobody cares. But if you are married and you don’t give birth, the family of the man will not compromise with you.” If a wife fails to bring her husband posterity, the mother-in-law may encourage her son to find another wife. Marriages may be severed and low social status assigned when women cannot have children: “If you don’t have a child, it becomes a pity. You may feel sorry for that. You will not be happy for not having a child.” The midwife said, “When somebody doesn’t have a child like she’s supposed to, they will try every means. Some will be going to pray in their homes. Some will be going to fetish priests. Some will be going to gynecologists.” Religious teachings also influence women’s desire to have children. A mother of five who had given birth on the path to the clinic said, “If they [women] really have the capacity to give birth, they should give birth because giving birth to children is good. [It is] what God loves.” Mothers gain a sense of self-confidence through having given birth successfully:

292 293 294

[Because] I have been able to give birth to twins, I know that I can take good care of life—make sure I take proper care of them so that they will grow up and become greater persons in life.

295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315

Infertility, commonly referred to as “barrenness,” is viewed as a social tragedy. People in the Ashanti Region assume that a woman’s barrenness is the result of illegal abortions during adolescence: “Most [women] . . . it’s not like God created them to be barren, but at times, when they are young they do abortions and other things. That is why, when they are old, they can’t give birth to children.” Infertile women usually are viewed as being wicked. Barrenness also may be caused by “destiny.” One informant said that infertile women, “are born to be barren. God will never make anyone barren, so the devil causes.” Infertile women often are considered to be witches. According to Ghanaian law, abortions are illegal, but it is estimated that 20% of pregnancies in Ghana are aborted (Lithur, 2004). Abortion-related deaths are the most frequent cause of maternal mortality (Mills, Williams, Wak, & Hodgson, 2008). Traditional healers such as herbalists and okomfos who have no formal obstetric training usually perform abortions or use herbs to induce abortions. Physical means, such as beatings, also are employed to attempt to induce abortions. Many study participants said they would not consider having an abortion and reported that family members and friends also discouraged them. A 15year-old girl who gave birth at the climic said she knew of “uncountable” girls from school who had died from having an abortion. Her fear that she too could die deterred her from seeking to abort her unwanted pregnancy.

UHCW_A_434563

702xml

January 4, 2010

22:32


9

316 317

Another woman who had given birth in her hamlet home expressed the reasons why women hesitate to consider abortions:

318 319 320

It is murder, one, and so it’s a sin, and, second, if you go and abort a baby, you don’t know what the baby will do in the future, so they [the community] don’t respect you and say bad things about you.

321 322 323 324 325 326 327 328

Mothers also believe their unborn child may be able to break through poverty and look forward to their children helping them financially when they are older, so abortion may be a critical mistake. Another concern about abortions is complications: “The mother will attempt to abort the baby. The medicine she takes to abort the baby, maybe it will not work and it will deform the child.” Compelling reasons, however, may prompt a woman to abort her pregnancy. One informant shared her story of how her boyfriend encouraged her to abort her first pregnancy:

329 330 331 332 333

He feared that when the family members heard about this they would have beaten or caused him harm. . . . When you go and take someone’s daughter which you haven’t married and you impregnate her, the family members will take you [to] the law—they will send you to prison or something. That is why he was afraid.

334 335 336 337 338 339 340 341 342 343 344

There are social expectations for women to have children at the right time, in the right situation, to have an appropriate number of children, and to rear their children in the right way. One young mother shared how she felt when she found out she was pregnant: “I was a little bit afraid, . . . because I was schooling. . . . [I was afraid of] my father. . . . He had spent a lot of money on me. He was angry.” Economics play a large role in determining the number of children a woman should have. If a woman has more children than she can provide for, she will be considered by the community to be irresponsible, foolishly getting pregnant due to lack of self-control. Conversely, if a woman has only one or a few chidren when she has the means to provide for more, she may be viewed as selfish:

345 346 347 348

If you don’t give birth, they will say you are barren. If you give birth to five, people will say that, “Oh, you are not having money and you have given birth to five children. How can you look after them?” But as for the two, it’s okay. Nobody will talk about it.

349 350 351 352 353 354

The Ashanti culture, rich in tribal heritage, has a long tradition of having large families, “If I had money, I would have given birth to about 10. Our ancestors used to give birth to many children. You have to also give birth to many people so that they will be in the family.” Women frequently expressed a sense of satisfaction by increasing the size of their families and continuing the generations.

UHCW_A_434563

10

702xml

January 4, 2010

22:32


355

Women are motivated, because of their fears, to have many children:

356 357 358 359

One is not enough. I don’t know what will happen later on. Maybe the child will die. So if you give birth to only one child, you will suffer later on. Maybe the child will die. So if you give birth to only one child, you will suffer later on.

360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387

Another mother explained: “I made up my mind not to give birth [to another child], but since two died, I needed to replace them. That is why I continued to have this baby.” Another incentive for women to bear children is to have someone who will care for them in their old age: “Here in the Ashanti Region, if you give birth, people respect you a lot and after all the child will come and look after you when you are old.” Another informant felt that, “the reward [for giving birth] is the time the child will grow and he too—in time he will take care of you.” Economic considerations also were discussed, “Giving birth to this baby has made us go through a lot of hardship. My husband and I are going through financial problems.” Clark (2000) identified the economic responsibilities of Ghanaian mothers. The Asante gender framework still sets up tensions between work and motherhood, but these focus on the financial demands of motherhood rather than on the labor demands of child care. Asante ideals and practices underline the importance of economic support in enacting motherhood, as a continuation of childbirth itself. The ideal division of financial responsibilities between mothers and fathers makes mothers responsible for daily sustenance. One informant reported that she and her sister were pregnant at the same time. Shortly after giving birth, her sister died and the woman adopted her nephew. Her husband would not support the adopted baby, telling his wife to abandon the adoptive child. She refused and had not heard from her husband for months. She had given birth to their child and was caring for the two children by relying on her savings and the generosity of her extended family, friends, and members of the community. A mother of twins by Cesarean birth explained that to pay the 450 Ghana cedi cost of medical expenses (approximately U.S.$450), they had taken out a loan from friends and were making weekly payments.

388 389

Accessing Health Care: Biomedicine, Ethnomedicine, and Spiritual “Cures”

390 391 392 393 394

Health care options include biomedicine, ethnomedicine, and the use of spiritual “cures.” Okomfos, the fetish priests, primarily address issues of spiritual sickness. Spiritual sicknesses are physical symptoms that may be a punishment for a spiritual offense or a curse placed upon a person by a witch or evil spirit (Wilson, 2006). Okomfos may direct individuals to make appropriate

UHCW_A_434563

702xml

January 4, 2010

22:32


11

395 396 397 398 399 400 401 402

animal sacrifices, oblations, or monetary donations to the shrine, or to take a traditional herbal medicine. It is believed that through strict obedience to the okomfos words, spiritual disease may be healed. Herbalists bridge the gap between spiritual healing of diseases and Western medicine, and most childbearing women do not rely wholly on Western or traditional medicine, but they take an integrated approach. Okofomos and herbalists may be certified to treat both spiritual and physical illnesses, having registered and paid a fee. One woman explained:

403 404 405 406

Those who have this kind of disease go to [herbalists] because it is a traditional disease so you cannot go to the hospital and get the medicine. You can go to the herbalists; then you get the medicine for that kind of disease.

407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430

Most women took advantage of health care services and recommendations: When I was pregnant I visited the hospital regularly; I made sure that I ate good, nutritious food; and also I took all the drugs [vitamins] that were given to me at the clinic. Pharmaceuticals often were supplemented with traditional mediation proscribed by an okomfo or herbalist: “I made sure that I took all the drugs they gave me at the clinic. . . . At times, too, I prepared herbs which I knew myself and added it to the drugs that they would give me at the hospital.” Childbearing women who do not give birth in a clinical setting rely upon TBAs who may have received formal training or have gained experience by assisting neighbors, friends, and family members to give birth. Many of these women have helped with the births of nearly entire generations in the villages, and they are often highly respected. Informants who gave birth at home expressed that obtaining transportation to a clinic to give birth was financially or logistically impossible and they often lacked the financial means to pay for health care expenses. Most mothers relinquished decision making to the health care providers, as one mother said: “When I went to the clinic, I made sure that I left everything to them [the attending staff] because I knew they had learned more about childbirth and that they would be able to help me give birth safely.” Mothers never verbally disagreed with any decision made by the staff; however, the mothers expected providers to be gentle and patient. A first-time mother shared her positive experience: “The nurses were very good and they weren’t so harsh on me and they didn’t scare me, so I was happy.”

431

Viewing Childbirth as a Dangerous Passage

432 433

Every informant knew a woman who had suffered a perinatal or neonatal loss or who had died from childbirth complications. The midwife said,

UHCW_A_434563

12

702xml

January 4, 2010

22:32


434 435 436 437

Normally, what makes people to be afraid when they are pregnant, [is] when they hear that maybe somebody had their child and died, maternal death or any child death. They will be thinking otherwise, “Is it going to happen to me as well?”

438 439 440 441 442 443 444 445 446 447 448 449

Another participant echoed this sentiment: “When I visited the clinic, someone came, delivered, and she lost her life, so I was afraid something like that would happen to me.” Another mother said, “I have seen some women who died after . . . giving birth.” This “junction of life and death,” as one woman described birth, is potentially dangerous for both mother and child. Another mother stated, “Some people go [to the clinic to give birth] and they won’t come back again. They will die [or] the child will die.” One of the informants experienced prolonged labor, and she was told that she would lose her child if the birth took much longer. She later said, “[When the nurse said that], I thought I had toiled in vain and all the difficulties I had passed through had been a waste.” Fear of death is a reality for Ghanaian women giving birth:

450 451 452 453 454 455

What I feared about childbirth I have heard from my mother and grandmother. Some women, when they go to give birth, after the baby had come, the placenta may not come, which can kill the woman. [For] others, everything will be okay during childbirth, but after 2 to 3 days, the mother of the child may die. Some will bleed after childbirth, which also can kill them.

456 457 458 459 460 461 462 463 464 465 466

Tragically, one of the study participants, the mother of six children who gave birth at home, died a week following the interview of complications of malaria. This underscores the reality of the tenuous nature of life in Ghana. There is also a fear of having a child with a disability: “I was afraid maybe the child would be paralyzed, blind, or dumb. . . . I thought that maybe the child would die after I had delivered or that the child would be deformed.” This fear may be perpetuated by a clinic practice. To encourage women to obtain an ultrasound, photographs of children born with severe anomalies are shown, and the women are told that while the scan may not prevent their children from being born with physical defects, it will allow the family to prepare. One informant said,

467 468 469 470 471

You can die, you can bleed during delivery. And then, even, the child may come out with the leg first. That is why they normally tell us to go for the scan. Sometimes, some of them don’t go for the scan. So, during delivery, that is the time the nurse will realize the baby is coming with the leg. That is where it may sometimes kill the baby, the mother, both.

472 473

Another major concern for mothers is the fear of a Cesarean birth. A mother shared, “When they do [an] operation, it is very painful and

UHCW_A_434563

702xml

January 4, 2010

22:32


13

474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491

sometimes after operation, some people, they get some stomach problems.” Another woman said, “You can die during the childbirth or, at times, some people when they go and there’s [an] operation, after the operation they will not be able to get up again.” One mother defined a successful birth as “having my own life and the life of my child.” Women rely on both their religious devotions and health care at the clinic, often in conjunction with traditional healers and the use of herbs. Women exercise faith that God will bless them and their children with a successful birth. One mother who had given birth at home said, “My main goal when I was going to give birth was that God should help me give birth successfully without any problems.” An informant who gave birth to twins after losing a child previously said, “I was not afraid. I left everything to God. As for me, I was not afraid because I knew God was in control.” Prayer plays a major role in helping mothers have confidence with their pregnancy and childbirth. A mother of 12 who had lost two of children said, “When I found out that I was pregnant, . . . I thanked God for my pregnancy and prayed that He would protect me through my pregnancy and childbirth.” Personal devotions continue during pregnancy and while giving birth:

492 493 494 495 496

You have to pray so that you leave everything to God, so that God will take control. . . . During that time, everything is in prayer. You will be praying . . . every time. From the time that you knew that you were almost ready to deliver, you start praying and you make your mind set that you are going to give birth to the child.

497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515

One mother recounted, “When I went to the clinic, I climbed [into] the hospital bed and all my thoughts at that place were that God should help me, ‘God have mercy on me! Oh, help me to deliver safely!’” Both Christian and Muslim congregations often hold prayer meetings in which specific blessings are requested for childbearing women: “They prayed so that there would not be any problems during delivery and then they prayed so that . . . you will go and come back with your child.” One woman who had postpartum hemorrhage following her first birth related, “They prayed for me that God would not let me go through that experience again when I was giving birth to the second born.” On the other hand, one mother said, “Because I didn’t go to the prayer meeting very often, I had bad dreams that I may be walking at the cemetery; someone may die in my dreams.” Another informant said, “If you are pregnant and do not go to prayer meetings, you can even die as you are giving birth.” While the family and friends are not permitted in the birthing room, there is a waiting area provided nearby where supporters pray for the mother. Even the clinic staff clinic incorporate prayer. The midwife reported, “We pray against it [maternal and newborn death]. By God’s grace, everything has gone well.”

UHCW_A_434563

14

Q6

702xml

January 4, 2010

22:32


516 517 518

Many women who gave birth at home said that they would give birth at the clinic. Women who had given birth at the clinic said they would advise their friends to do the same:

519 520 521 522 523

Because that is where they will take good care of you. At times in the house, normally the women help you when you are about to deliver. They will say, “Do this. Do this.” At the end, you may lose even the child or you, the mother, may die. So it is better to go to the clinic so that they will give you the medicine.

524 525 526 527

Occasionally, despite the mother’s best efforts and faith, a child may still die, which was considered as Divine Will, “I think God actually called that baby home. It was God who called that baby.” Another mother explained, “God gives and at the same time He takes.”

528

Experiencing the Pain of Childbirth

529 530 531 532 533 534 535 536

Pain was a memorable part of giving birth, with the women saying that there is nothing more painful than childbirth, even death. The belief was expressed that women suffer the pains of childbirth because it is God’s Will, a punishment for disobedience rooted in the Christian–Islamic teachings about the fall of Adam and Eve. The midwife at the clinic said pain medication is rarely administered because childbirth is a natural albeit painful process. An informant who gave birth to her first child at 32 two weeks said,

537 538 539 540

Because it has come to the time for you to deliver, it is your own cup of tea to try hard so that you can be able to give birth. I didn’t cry. The child is in your womb, so you will try your best. No one can do it for you. You are the only one who will do it.

541 542 543

Women were encouraged to stay quiet during birth. “You can cry,” the midwife tells women who are giving birth, “but you may not shout.” One study participant said,

544 545 546 547

Whether you cry or not, it doesn’t make it any easier, so there’s no need for you to cry or shout. Whether you cry or not, you are going to give birth to the child so if there is pain or anything, you don’t have to cry; you have to give birth to the child.

548 549 550 551 552

Traditional birth attendants (TBAs) also encouraged women in labor to be quiet, as reported by a woman who gave birth at home: “[The TBA] said I should just be quiet and strengthen myself. The baby would soon come out.” Generations of women encourage this practice of quietly enduring childbirth. A first-time mother said, “My mother told me it is very painful, so

UHCW_A_434563

702xml

January 4, 2010

22:32


15

553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571

when it comes I should harden myself and strengthen myself.” Even mothers who gave birth alone reported being silent. Women often refer to those who do cry out or scream in pain as having been raised being “pampered.” There is a belief among some women that crying out delays the birth and may result in the mother being referred to a hospital, so stoicism may prevent the physical and financial consequences of such a referral. On the other hand, some women explained why they believe screaming is appropriate at times: “Maybe those [women who cry out] are afraid that when they are giving birth to the baby, the baby or she will die.” Another informant explained why she shouted during the birth of her fourth child: “The pain was continuous. That is when I actually shouted a little bit, when the baby was about to come.” Because childbirth pain is seen as natural, there are unique views of pain medication. One woman who gave birth at home said, “I believe if you take any drug at this time it will not work, because it is time for me to give birth so the pain has to come.” A woman who gave birth with the support of her mother-in-law said, “Even if you drink some medicine [the pain] will not go. It will still be there.” The most common belief is divine intervention, which helps mothers endure childbirth pain:

572 573 574 575

Whether I cried or shouted, I was going to give birth to the baby, so there’s no need for us to cry or shout. All that I needed to do was to keep calm and being praying in my mind to God so that He could help me to have a safe delivery.

576 577 578 579 580 581 582 583 584 585

Another mother explained, “The time that you deliver, the pain is so severe that if God hasn’t intervened, you will die at the spot.” One woman who walked back home after giving birth on a path that weaves uphill through the forest to the clinic said, “After you have been able to bring forth the child, you will become free—you may not get some pains again.” The midwife related her personal experience: “When you carry your baby in your arms, then all the things you know: the pains, the problems, you will have to see the child and you will forget about those things.” Another informant explained that women endure the pains of childbirth “because they need the children.”

586

Fearing the Effects of Witchcraft on Birth Outcomes

587 588 589 590 591 592

There is a traditional Ashanti saying, “Bayie w¨o.efie biara anaa abusua biara mu,” which means, “In every house, in every extended family, there is a witch.” Witches are infertile women who do the work of the adversary in making families miserable by destroying those things they have the most joy in, hence the increased belief in witchcraft during childbearing. There is a fear of offending one’s family members: “If you insult people who are witches,

UHCW_A_434563

16

702xml

January 4, 2010

22:32


593 594 595 596 597

they can plot against you during your [pregnancy] and they can fight at your birth.” Jealousy specifically may be an issue: “If somebody is your enemy or somebody envies you and that person is not spiritually good, she or he can give it [a spiritual disease] to you.” Witches may curse the mother, the unborn child, or both. One mother said that there is a woman who visits the clinic:

598 599 600 601

[She] is also a witch, so when she sees your child she can transfer some of the disease to you. And sometimes even if you are pregnant . . . if there is some of your nakedness or you eat outside, the person can transfer [a spiritual disease to your child].

602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621

Curses are believed to cause spontaneous abortions as well as many congenital diseases and disabilities (Tiebere et al., 2007). The fear of witchcraft escalates at the time of the birth and contributes to health care decisions. Some informants said that it is safer to give birth at the clinic because witches are unable to reach you in this protected environment. One woman expressed her view that it is safer to give birth at home because no one sees you traveling to the clinic and no one knows when you are facing this dangerous period of time. The fear of being cursed also plays a role in mothers being quiet during the birth, so as not to draw attention to themselves. The midwife said a woman laboring at the clinic had complications and was referred, via the district hospital in Mampong, to the teaching hospital in Kumasi. An extended family member came looking for the mother, and the staff told her where she had given birth. The woman visited the new mother, who subsequently died. The death was attributed to the practice of witchcraft. This experience set the precedent for not allowing family members or friends in the birthing room during the birth and strict visiting rules in the recovery house. While the fear of witches is ominous, there is protection available. Women rely on their religious devotions to grant them divine intervention and safety from curses:

622 623 624 625

When you are pregnant, you should remove these things from your mind, like witchcrafts and other people who will harm you. [If] you have faith in the Lord, [in] everything you are doing, God will help you so that you will come out successful.

626 627 628 629

Another woman said, “I believe that witches exist, but I am not afraid of them because I have God.” Prayers, church attendance, and righteous living, including seeking forgiveness from God if the pregnancy is out of wedlock, are believed to provide women with the necessary protection against witchcraft.

UHCW_A_434563

702xml

January 4, 2010

22:32


17

631

DISCUSSION AND IMPLICATIONS FOR RESEARCH AND CLINICAL PRACTICE

632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657

In the Ashanti Region of Ghana, childbirth is viewed as a natural social event, with biomedicine, ethnomedicine, and spiritual means utilized by childbearing women (Tabi, Powell, & Hodnicki, 2006). Ghanaian women have many fears related to infertility, abortion, pain, maternal and infant mortality/morbidity, family size, and superstitions such as a belief in witchcraft, and they face these fears with reliance on God and religious devotions such as prayer (Gyimah, Takyi, & Addai, 2006). For example, infertile Ghanaian immigrant women living abroad utilize spiritual healers to assist them to become fertile, or they may go home to a prayer campus in Ghana and stay for extended periods of time to treat their infertility by the “opening of wombs” with prayer (Yebei, 2000). Spirituality is an important dimension in many cultures (Hall, 2006). This study verifies that concern for this aspect of humanism must be respected by clinicians. Health beliefs and cultural attitudes are described in the Health Belief Model, which guided this ethnographic study. The provision of holistic care can contribute to positive birth outcomes and long-term health and wellbeing in women. For example, SAC clinic personnel encouraged mothers to pursue divine help even if they did not share the same faith. Cultural beliefs that were harmless or potentially helpful were supported by care providers, and women were educated about cultural practices that were potentially harmful. A universal belief in witchcraft including spiritual sickness (sumsumarye) influences childbearing women and contributes to seeking the assistance of traditional healers. Many more women used traditional remedies (herbal medicine) than they admitted to clinicians, and this is also the

630

TABLE 1 Clinical Implications • Increase the quality of vital registration systems so accurate data related to maternal and neonatal morbidity and mortality are available. • Implement Safe Motherhood Initiatives in rural areas. • Incorporate spiritual and cultural assessment in health care encounters and demonstrate respect for these dimension of women’s lives, listening carefully to the voices of women. • Health care should be based on women’s strengths, including traditional knowledge and cultural practices that are health promoting. • Provide education in health care encounters and involve women in making health care decisions, including the promotion of family planning initiatives. Repeated “booster doses” of information should be provided at each health care encounter. • Encourage disclosure of the use of complementary therapies. • Recognize that enhancing the health of mothers is pivotal to the promotion of health in families and communities. (Andrews & Boyle, 2008; Hall, 2006; UNICEF, 2008)

Q7

Q8

UHCW_A_434563

18

Q9

702xml

January 4, 2010

22:32


658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685

case among Western childbearing women who used complementary alternative medicine (CAM), which includes prayer and other spiritual strategies (Ranzini, Allen, & Lai, 2001). Caregivers should foster clear, open, nonjudgmental communication based on trust so women will disclose what they are using. Clinicians should be aware of potential pharmacological–herbal interactions in order to ensure healthy outcomes. Since many people globally are using complementary therapies, which includes 1,800 practices (Fontaine, 2005), this is an important consideration in health care delivery. Negative birthing outcomes usually are attributed to witchcraft. Abortions are looked down upon for religious, physical, and social reasons, and infertility generally is attributed to either adolescent abortions or a curse. There are social pressures for women to bear an “appropriate” number of children, to have healthy children, and to be financial providers for their children, all of which reflect on the Ghanaian woman’s motherhood (Tettey, 2002). Similar beliefs may be found in other traditional cultural groups. All of the pregnancies were reported as unintended, suggesting the need for further education and other resources for family planning. Culture is a vital component of family planning and cannot be overlooked. There is not a “one-size-fits-all” family planning initiative. Providers should ensure they understand the roles that religious and societal expectations play in family planning. Involving women in decision making is essential. This study reaffirms the importance of listening to the voices of childbearing women and respecting their perspectives. Qualitative research findings can contribute to evidence-based practice (Zuzelo, 2007). Further research is needed, with focus groups of Ghanaian childbearing women becoming participants in designing health care delivery models. Evaluation of innovative interventions outcomes should be conducted.

686

REFERENCES

687 688 689 690 691 692 693 694 695 696 697 698

Agovi, A. M. A. (2003). Just me and my God—Childbirth experiences of religiously motivated Ghanaian women. Unpublished manuscript. Knoxville: University of Tennessee, Knoxville. Akrong, A. (2000). Neo-witchcraft mentality in popular Christianity. Institute of African Studies: Research Review, 16(1), 1–12. Amoh-Agyei, G. (2004). Evaluation of comprehensive emergency obstetric care in the Mampong District Hospital. Unpublished postgraduate thesis, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana. Andrews, M. M., & Boyle, J. S. (Eds). (2008). Transcultural concepts in nursing care (5th ed.). Philadelphia: Lippincott, Williams & Wilkins. Biritwum, R. B. (2006). Promoting and monitoring safe motherhood in Ghana. Ghana Medical Journal, 40(3), 78–29.

UHCW_A_434563

702xml

January 4, 2010

22:32

Ghanaian Perceptions of Childbirth 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745

19

Callister, L. C. (2007). Global maternal mortality: Contributing factors and strategies for change. In A. S. Loveless & T. B. Holman (Eds.). The family in the new millennium (vol. 3, pp. 270–285). Westport, CT: Praeger Press. Callister, L. C., & Khalaf, I. (2009). Culturally diverse women giving birth: Their Q10 stories. In H. Selin (Ed.). Childbirth across cultures. New York: Springer. Clark, G. (2000). Mothering, work, and gender in urban Asante ideology and practice. American Anthropologist, 101(4), 717–729. D’Ambruoso, L., Abbey, M., & Hussein, J. (2005). Please understand when I cry out in pain: Maternity services during labour and delivery in Ghana. Bio-Medical Central Public Health, 5(140), Retrieved January 5, 2008, from www.biomedcentral.com (doi: 10.1186/1471-2458-5-140). Dauda, I. (2005). Determinants of maternal choice of place of delivery in the Nkoranza District of the Brong/Ahafo Region. Unpublished postgraduate thesis, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana. Fegan, G. W., Noor, A. M., Akhwale, W. S., Cousens, S., & Snow, R. W. (2007). Effect of expanded insecticide-treated bednet coverage on child survival in rural Kenya: A longitudinal study. The Lancet, 370, 1035–1039. Fontaine, K. L (2005). Complementary and alternative therapies for nursing practice (2nd ed). Upper Saddle River, NJ: Pearson Education. Ghana Health Service. (2007). Afigya Sekyere District annual report for 2006. Agona, Ashanti, Ghana: Author. Ghana Health Services. (2007). Afigya Sekyere District Annual Report. Agona, Ashanti, Ghana: Author. Grace & Powers. (2009). Claiming our care: Appraising qualitative evidence for nursing questions about human response and meaning. Nursing Outlook, 57, Q11 27–34. Gyimah, S. B., Takyi, B. K., & Addai, I. (2006). Challenges to the reproductive health needs of African women: On religion and maternal health utilization in Ghana. Social Science and Medicine, 62(12), 2930–2944. Gyimah, S. O. (2006). Cultural background and infant survival in Ghana. Ethnicity and Health, 11(2), 101–120. Hall, J. (2006). Spirituality at the beginning of life. Journal of Clinical Nursing, 15, 804–810. Jansen, I. (2006). Decision making in childbirth: The influence of traditional structures in a Ghanaian village. International Nursing Review, 53(1), 41–46. Lithur, N. O. (2004). Destigmatising abortion: Expanding community awareness of abortion as a reproductive health issue in Ghana. African Journal of Reproductive Health, 8(1), 70–74. Maimbolwa, M. C., Yamba, B., Diwan, V., & Ransjo-Arvidson, A. B. (2003). Cultural childbirth practices and beliefs in Zambia. Journal of Advanced Nursing, 43(3), 263–274. Mills, S., Williams, J. E., Wak, G., & Hodgson, A. (2008). Maternal mortality decline in the Kassena-Nankana District of Northern Ghana. Maternaland Child Health Journal, 12, 577–585. Mitchell, W., & Irvine, A. (2008). I’m okay, you’re okay?” Reflections on the well being and ethical requirements of researchers and research participants in conducting

UHCW_A_434563

20

Q12

Q13

746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775 776 777 778 779 780 781 782 783 784 785 786 787 788 789 790 791 792 793

702xml

January 4, 2010

22:32


qualitative fieldwork interviews. International Journal of Qualitative Methods, 7(4), 31–44. Noor, A. M., Mutheu, J. J., Tatem, A. J., Hay, S. I., & Snow, R. (2009). Insecticidetreated net coverage in Africa: Mapping progress in 2000–2007. The Lancet, 373, 58–67. Ranzini, A., Allen, A., & Lai, Y. L. (2001). Use of complementary medicine and therapies among obstetric patients. Obstetrics and Gynecology, 97(491), S46. Roper, J. M., & Shapira, J. (2000). Ethnography in nursing research. Thousand Oaks, CA: Sage. Rosato, M., Mwansambo, C. W., Kazembe, P. N., Phiri, T., Sokso, S., Lewycka, S., Kunyenge, B. E., Vergnano, S., Osrin, D., Newell, M. L., & de Costello, A. M. (2006). Women’s groups’ perceptions of maternal health issues in rural Malawi. The Lancet, 368, 1180–1188. Speziale, H. J. S., & Carpenter, D. R. (2007). Qualitative research in nursing: Advancing the humanistic imperative (4th ed). Philadelphia: Lippincott, Williams & Wilkins. Spradley, J. P., & McCurdy, D. W. (1972). The cultural experience: Ethnography in complex society. Prospect Heights, IL: Waveland Press. Stretcher, V. J., & Rosenstock, I. M. (1997). The health belief model. In K. Glanz, F. M. Lewis, & B. K. Rimser (Eds). Health behavior and health education: Theory, research, and practice (2nd ed., pp. 41–59). San Francisco: Jossey Bass. Tabi, M. M., Powell, M., & Hodnicki, D. (2006). Use of traditional healers and modern medicine in Ghana. International Nursing Review, 54, 52–58. Tettey, E. R. (2002). Motherhood: An experience in the Ghanaian context. Accra, Ghana: Universities Press. Tiebere, P., Jackson, D., Loveday, M., Matizirofa, L., Mbombo, N., Doherty, T., Wigton, A., Treger, L., & Chopra, M. (2007). Commuity-based analysis of maternal and neonatal care in South Africa to explore factors that impact utilization of maternal health services. Journal of Midwifery and Women’s Health, 52, 342–350. United Kingdom. (2006). Control of immigration: Statistics: United Kingdom 2005. London: The Stationery Office. United Nations International Children’s Emergency Fund (UNICEF). (2006). The state of the world’s children 2007. New York: Author. United States Department of Homeland Security. (2007). Yearbook of immigration statistics: 2006. Washington, DC: U.S. Government Printing Office. United States Department of State. (2007). International religious freedom report 2007. Retrieved January 20, 2008, from http://www.state.gov/g/drl/rls/irf/2007/ 90100.htm Wiamoase Salvation Army Clinic. (2007). The Salvation Army Clinic 2006 Report. Wiamoase, Ashanti, Ghana: Author. Wilson, B. (2006). The drumming of traditional Ashanti healing ceremonies. Pacific Review of Ethnomusicology, 11, 1–17. Yebei, V. N. (2000). Unmet needs, beliefs, and treatment-seeking for infertility among migrant Ghanaian women in the Netherlands. Reproductive Health Matters, 8, 135–141. Zuzelo, P. R. (2007). Evidence-based nursing and qualitative research: A partnership imperative for real-world practice. In P. L. Munhall (Ed.): Nursing research: A qualitative perspective (4th ed., pp. 481–499).