UNIVERSITY OF PENNSYLVANIA - AFRICAN STUDIES CENTER
Paper prepared for the Fifth Annual African Studies Workshop "Cross-Currents in Africa" (organized by the Penn, Bryn Mawr, Haverford, and Swarthmore Consortium) for a panel entitled "Local Solutions and Existential Dilemmas" (University of Pennsylvania, October 17, 1997).
Field Research for this project was funded by a Fulbright-Hays Doctoral Dissertation Research Abroad Grant. A 1992 pilot study was funded by the University of Pennsylvania Department of Anthropology, The Explorers Club, and Sigma Xi Scientific Research Society.
Kathryn Linn Geurts
All Rights Reserved
This paper will examine conflicts between national and local strategies to utilize Traditional Birth Attendants (TBAs) to improve maternal and infant care in rural Ghana. In the 1980's and early 1990's the Ministry of Health recruited locally recognized village midwives to receive education, training, and basic materials to use in deliveries. The midwives then recieved certificates which bestowed upon them the title and designation of community TBA. Due in part to this process they developed a heightened sense of their own individual and collective importance in the national efforts toward family planning and safe motherhood, and although often labeled "illiterates" the TBAs were highly conscious and articulate about the significant role they played in primary health care. Despite their vital function, at the local level TBAs often experienced exclusion from the formal medical system and derision and disrespect from many local health officials; their clients rarely paid them, and local district councils did not support them with financial or material assistance. Unable to replenish the supplies in their kits and lacking adequate facilities, they sometimes reverted to unhygienic and dangerous practices which they recognized as threatening to the neonate, their clients, and themselves. Discouraged by these and other conditions, some began to withdraw their services from the community while others tried to organize for change. Based on ethnographic case studies from twenty months of fieldwork in southeastern Ghana, this paper will examine the critical and paradoxical role of traditional midwives and how they have yet to achieve their potential due to intractable political and economic obstacles at the local level.
Between 1992 and 1995 I spent approximately 20 months in southeastern Ghana conducting ethnographic research among Anlo-speaking peoples. Anlo is a dialect and sub-set of Ewe-speakers who inhabit most of the Volta Region of Ghana and much of southern Togo, as well as residing in Accra and other areas throughout West Africa. Individual Ewe-speakers and their families have also migrated to locations all over the world. The coastal area from Anyanui to Keta or Kedzi, and north of the lagoon to Anyako, is typically considered the heart of Anlo-land, and Anlo-Ewe speakers have inhabited this homeland for more than three hundred years.
Many Anlo-speaking people view the arrival of a new child as a joyous event and as the return of an esteemed ancestor. Seven days after the birth, many families perform an outdooring ceremony to introduce the baby to relatives and to the universe. Anlo-land is therefore not a context in which infants are treated with ambivalence, despite the poverty in which many of these families live. Newborn babies are welcomed wholeheartedly. However, all this jubilation is at the same time tempered by the sobering reality that in rural contexts in Ghana, childbearing is still one of the most dangerous moments in a woman's life. Furthermore, families are acutely aware of the fact that for every six children that a rural woman bears, a high likelihood exists that only three will survive past the age of five or ten.
This paper focuses on the question of who controls and is responsible for this domain. Is the well-being of mother and child during the critical process of birth her own responsibility and that of her family? Are her lineage elders in charge of the situation? Should the state and the district public health team intervene? What role should older women in the village, who have often delivered dozens and even hundreds of babies, play in this ordeal? And if the mother or baby dies, who is to blame? In a context of rapid social change, breakdown of traditional forms of social organization, and an increasing dominance of the biomedical model organized around specialization, Anlo-speaking people are struggling with these questions on a daily basis, with the outcome often determining the life or death of a woman and her child.
One response by the Ghanaian state has been to identify and train specific individuals in rural communities to perform routine deliveries in the home and refer complicated cases to the hospital or local clinic. As simple and straightforward as this plan to utilize "traditional birth attendants" may seem, in reality it is fraught with complications. This paper will explore the social context of birth and look specifically at the role that traditional midwives play in reproductive politics and management of birth in a village in southeastern Ghana.
There are few people in the western world who would not agree that "family planning" of some sort is a good thing. Most feel that limiting the number of children in a family enhances the quality of life and health status for all individuals involved. Secondly, many believe that each "planned child" deserves assiduous prenatal care, and should be closely monitored by someone qualified to manage pregnancy and birth. In fact, these two ideas underpin much of the policy and programming of both public and private sector international development agencies supplying aid to so-called third world nations such as Ghana (World Bank 1989:69-72). The philosophy is also at the center of the UNESCO and WHO campaigns aimed at "safe motherhood and child survival," and the government of Ghana has taken this mandate to heart.
Fertility and mortality statistics for the 1980's showed that out of 1000 live births in Ghana, between 77 and 100 infants would die (compared to 33 in Sri Lanka, 32 in China, and under 10 in most European nations) (World Bank 1989:65; Murdoch 1980:15; and MOH 1990:3). The maternal mortality rate was between 500 and 1500 per hundred thousand live births in Ghana, compared to under 25 per hundred thousand for countries in Europe (MOH 1990:3). In response to these conditions and with significant amounts of aid from international agencies, one tactic employed by Ghana's Ministry of Health was to aggressively develop and implement a program aimed at recruiting village midwives to upgrade their skills so that they could more safely manage routine births and refer complicated cases to various public health facilities at the district level.
This intensive "Traditional Birth Attendant" (henceforth TBA) training program was inaugurated in 1987 and targeted mainly rural areas throughout the country. Program goals included improving the delivery skills of the TBAs and equipping them to perform certain pre-natal and postpartum care tasks. In addition, they were educated about primary health care topics such as family planning, immunization, and oral rehydration therapy. The initial stage of this program involved a pilot study conducted in the Dangbe District, and then the national program was initiated in 1989 beginning with the Volta Region. In general their training included 12 sessions spread out over six weeks or up to three months. At the conclusion of the training each TBA received a certificate, an identity card, and a "kit" which contained two bowls (one medium, one small), a nail brush, soap and soap dish, packet of razor blades, hand towel, cord ligatures, plastic bag of cotton wool, contraceptives (condoms and foaming tablets), packets of Oral Rehydration Salts, a record book, and referral cards to send clients to the hospital or clinic (Ministry of Health 1990:14). After the initial training, follow-up supervision and monitoring was to be performed by the same health post staff member who conducted the TBA's sessions. This staff member was to "visit" the TBAs regularly and review basic practices, discuss recent cases, and collect statistics from the record books indicating deliveries and outcome. At the end of 1992, the Ministry of Health's records indicated that they had identified 1,385 TBAs (or "village/home midwives") in the Volta Region, and they had trained 529. Between 1992 & 1995 I conducted interviews with eleven TBAs and participant-observation based research with six TBAs in 4 villages in the southern Volta Region. The following account describes some of the effects of this program in one specific village, and highlights the uneasy confrontation between a biomedical model and traditional Anlo beliefs and practices concerning well-being and birth.
From the end of 1993 and into 1995 I lived in a village I will call Agbelidu, which was located west of Anloga and had a population of approximately 1500 people. In order to learn about childbirth, I tried to introduce myself to the various people in the area who were frequently consulted or called for a birth or during pivotal points in pregnancy. This small step itself was much more difficult than I anticipated, and a description of the process illustrates some important issues about how birthing gets negotiated in rural contexts. I learned that there were four women who had attended many of the births in Agbelidu for the previous fifteen or twenty years. Such women (and occasionally men) were referred to in the local language as vixela or afeme vixela which translates roughly as "home midwife." One vixela lived in the compound adjacent to ours, so I began by paying her a visit. As my assistant and I entered the compound, a man working on the roof shouted through the hole that "the white woman was coming" and the midwife quickly escaped out the back gate. This (or a similar) avoidance technique occurred each of the five or six times I attempted to make her acquaintance. While her tactics were less dramatic than the first vixela, the second midwife was conveniently never home when I called at her house. The third vixela patiently sat with me for half an hour or forty five minutes and answered most of my questions, though very curtly. She restricted her deliveries to members of a religious sect known as Blekete, and it was clear that she was not interested in allowing me access to that particular domain. The fourth vixela was the midwife designated to participate in the TBA training program. She was initially very eager to speak with me, and throughout the fifteen months I lived in Agbelidu she often visited my house, but she never once called me to one of her deliveries although I heard that she conducted at least three. Despite these seemingly insurmountable obstacles, I eventually established close connections with five additional TBAs in three adjacent villages, and attended approximately fifteen births during my stay. However, the situation within the context of Agbelidu is illustrative of some very important points.
Largely because of my status as an outsider and as a European or a white, many people assumed I was a doctor or a midwife and somehow connected to the district health team. Despite my efforts to change their minds, they could not imagine an outsider in any other category being interested in talking to them about birth. The vixela next door was therefore extremely reluctant to interact with me because she had been told by local public health officials to cease any involvement in delivering babies and refer all clients who approached her to either the hospital or to a designated TBA. Clearly she did not want to draw attention to herself, or to be reported (by me) to the hospital personnel, although my survey revealed that she continued to offer her services and attended a number of births while I lived next door. The second vixela who also avoided me had actually stopped delivering though not because anyone had instructed her to cease. She felt that clients ought to go to the designated TBA, and since she rarely received compensation for attending a birth, it was not worth her while to continue. The third vixela's religious convictions (which could be classified as a "secret society") constituted the reason she would continue to have clients as well as the reason I would not be granted access to her domain. The fourth vixela (who held the title of TBA) took a rather paradoxical relationship to me which directly mirrored her attitude about her own role.
Of the six TBAs in the four villages where I worked, Agbelidu's TBA was the most negative and cynical about their predicament. She said that she took her work as a TBA very seriously, and expected things to change once the formal program began. She attended the training sessions, and set up a special room within her own house. After Agbelidu's chief "beat the gong-gong" (to assemble the members of the village) and informed the community that she was the officially designated and trained TBA, she expected to receive a steady stream of clients. Instead, pregnant women continued to seek the assistance of the other three vixelawo (home midwives) which violated the goals she believed the program sought to achieve. Furthermore, even those clients who came to her usually failed to pay. She resorted to holding the woman and neonate hostage in the birthing room in her home, trying to force the family to pay for her services before they could retrieve the baby. This drama evidently lasted as long as three days, and since she had to feed the woman while they lodged with her, and the family still failed to pay, she found even this tactic useless. By the time I came to live in Agbelidu, she was turning most clients away. Those she did deliver were evidently familial relations so close that she was obligated to assist. So while she reported to me that no one was requesting her service, and she would promise that when they did she would call me to help, I knew from other sources that she was actually withdrawing from the TBA role. Her failure to call me during the few times she actually delivered was probably due to the close association she felt I had with the TBA program trainers and medical personnel.
What does this account reveal about prospects for well-being and birth in Agbelidu? Were women able to receive adequate care, and if so, from whom? How did this situation evolve such that the woman chosen and trained as Agbelidu's official TBA no longer wanted the "job?" Along these lines, it is useful to look at the numbers from a fairly informal and random survey I conducted to better understand the conditions in which women in this rural area were giving birth. For women who were living in Agbelidu and gave birth between 1979 and 1994 (about 15 years of information), there were 93 births reported in my small survey. Of those 93, only 4 were attended to by Agbelidu's designated TBA (either before she was the official TBA or after her training and title in 1987). Another 4 were attended by the designated TBA from the neighboring village. A total of 9 births reportedly occurred with no one at all in attendance: the woman delivered by herself. The next highest number was for 21 births attended by one of Agbelidu's other afeme vixelawo (home midwives) who were not trained or recognized by the district health team. After that, 27 births occurred in the public clinic (in Anloga) or at the district hospital (in Keta), attended by a biomedically trained midwife or by a doctor. But the highest number of all was for 28 births which occurred in the home, attended to or delivered simply by a relative. Many of these relatives had reportedly delivered numerous babies, so whether or not they deserve the title of vixela is open to interpretation, but they were not among the four clearly identified "village midwives" residing in Agbelidu.
In addition, out of the fifty five women in Agbelidu who participated in this part of the survey, three changed their pattern from consistently delivering at home to a final delivery (prior to the survey) in either the clinic or hospital. Eight women changed their pattern in the reverse: they had a track record of one or more deliveries in the hospital or clinic, and then went back to having their babies at home. One woman complained that some time around 1983 she went to the hospital, but ended up delivering on the hallway floor with no medical personnel present. Her subsequent children (born in 1985, 1990, and 1993) were delivered at home. Indeed, in one of my own cases when a TBA asked me to transport her client to the hospital, the TBA and I waited on a bench in the hallway while the midwife sat at a desk filling out forms, and the mother had her baby in the delivery room by herself. Due to the relatively informal nature and the small sample represented by my survey, I am not suggesting that these numbers are statistically significant. However, they certainly correspond to the results of my ethnographic work and are therefore notable for the qualitative features they display.
Following are two case studies which further illustrate the conditions in which a woman would decide where and how to give birth. The first describes a home birth that occurred in the compound where I lived. The second case began in a neighboring village but eventually ended up as a hospital birth. Analysis of the issues raised by these cases follows the edited and condensed accounts taken from fieldnotes.
Ama woke us around four a.m., explaining that Esi (her daughter) was in labor. She wanted me to drive to the neighboring village to fetch the TBA named Amenuvor. Once we retrieved the TBA and returned to Ama's house, we found Esi in her room sitting up on the edge of the bed. Her three year old son was lying on the bed behind her. Amenuvor sat on a stool in front of her, and Ama moved in and out of the room, bringing supplies. I sat on the edge of a wooden chair across the room from the bed, next to a bushel basket of mangoes spread across the floor. Esi had been headloading and selling mangoes in the market as recently as the previous day.
The room was very dark. Although electricity was connected to the house, the fluorescent bulb was burned out. With the aid of my flashlight, Amenuvor took the suction bulb from her kit and cleaned it out. She then accompanied Esi to the toilet to administer an enema. After they returned Amenuvor spread her red plastic mat on the cement floor, and covered it with old avo (cloth) she pulled from her kit. For the following two hours Esi's contractions were still more than ten minutes apart. Amenuvor instructed Esi to sit on the edge of a small, eight inch stool, and she positioned herself on the floor in front of Esi. She palpated and massaged Esi's abdomen, then dipped the forefingers of her left hand into her jar of shea butter and inserted them to check the extent of Esi's dilation. Amenuvor withdrew her fingers carefully and examined the width to gauge Esi's progress. In between contractions Esi alternated between walking back and forth between the bedroom and the main front room, lying down on her bed on either her right side or her back, and sitting on the edge of the tiny stool. She sometimes dozed while on the bed or sitting on the stool. Her son wandered in and out of the room; Grandma came in a few times to sit and observe; Ama brought more supplies as well as a thin white porridge for Esi to drink. By six in the morning people all over the compound were stirring, and several people came by to ask how it was going.
Some time between seven and nine a.m. the mood changed dramatically from the quiet and calm of the early hours to a tense and strained atmosphere. Esi's contractions came more frequently and her pain steadily increased. More significantly, Amenuvor seemed to detect that something was wrong. The first sign of this was when she withdrew the whisk from her kit, spit on it, and began brushing and stroking downward on Esi's abdomen. This ritual was performed when an affliction called enu was suspected: when animosity or bad will had occurred within the family or household, many believed that it could attack small children and pregnant women. Grandma came in to assist Amenuvor in chanting and recitations. As Esi's cries and exclamations grew stronger and more dramatic, more people arrived. Two older women from within the compound and three from without came to offer assistance and some provided herbs (fresh, dried, and powdered). Maggie from next door brought a small pot of thin porridge, poured some into a cup, and held it to Esi's lips so that she could drink. At one point when Esi was lying on the floor shouting and screaming from pain, seven or eight of the children from the compound gathered immediately inside her bedroom door. While several of them had come earlier in pairs to peek their heads in to see, and Esi's son and younger sister consistently wandered in and out, this group annoyed her terribly and one of the older women shooed them out and closed the bedroom door.
About this time Esi declared that she wanted to go to the clinic or hospital. Amenuvor and the older women all told her no. Amenuvor kept checking the amount of dilation, and massaging and manipulating Esi's abdomen. At one point she had me feel the skin where she was pressing and pushing, and she explained that the hardness (to Esi's far right side) was probably the buttocks or back. I realized then that the baby might not be in a vertex position; while I didn't know if the baby was totally sideways or transverse, it seemed to be in a seriously diagonal slant. Amenuvor kept trying to get Esi to stay on the little tiny stool so that she could apply pressure and massage, but Esi moved from the bed to the floor, kept walking around, and only returned to the stool once in a while.
At one point while Esi was on the stool, Amenuvor resumed the ritual brushing of her abdomen. The sequence of actions differed slightly from what I had observed before (at this or any other birth). Amenuvor spit both on the brush and on Esi's abdomen, and she also asked Esi to spit on her own stomach. After stroking the front (accompanied by a chorus of the older women's recitations), she had Esi lie down on her side, and Amenuvor brushed vigorously down her buttocks and back. In between certain strokes (both on the abdomen and on the back) she slapped the whisk against her left hand. Then Esi's great aunt came in with a calabash containing dried herbs. Amenuvor went outside, left the compound, and returned with some fresh herbs which she placed in the calabash. Ama added a powdered substance and hot or warm water. Amenuvor stirred the mixture with her fingers, then had Esi drink from the calabash and also chew some of the fresh herbs. In the midst of this Esi continued crying out loudly from pain, and beseeching the women to let her go to the hospital. She stated that this baby was much bigger and more painful than her first (which she had delivered three years previously at the public clinic). Amenuvor gestured with her fingers down the center of Esi's abdomen and sternly told her that at the hospital they would cut her open. The other women took their turns with the whisk brushing Esi's abdomen, buttocks and back, and Ama brought a bucket of hot water. Amenuvor instructed Esi to stand up and bend over, lowering her forearms and forehead onto the back of a wide, wooden chair. Keeping her legs apart, Esi's lower back was thus higher than her head. Amenuvor took a small towel brought by Ama and immersed it into the bucket. After ringing out most of the water, she applied the towel to Esi's lower back, pressed and stroked downwards past her buttocks. In repetition Amenuvor applied more pressure, using her upper body to bend over Esi and press hard.
After ten or more minutes of this posture, they let Esi lie down on Amenuvor's rubber mat. Gladys had gone to fetch a much larger whisk, and the ritual to remove enu recommenced but with greater intensity. The women took turns sipping the liquid from the calabash and spraying it back out onto Esi's abdomen. They also poured from the calabash directly onto Esi's skin, and tried to get Esi herself to drink from the calabash but she usually declined. They used the larger whisk to brush her abdomen. Esi protested a number of times that it was too hard and she asked them to stop. But the women persisted and eventually Esi was drenched. At this point Esi sat up on the mat, in the middle of a puddle, and just wailed out that she wanted to go to the hospital. She was crying intensely and pressing on her own abdomen. I looked to Esi's mother for any signal that I should get the car to transport them to the clinic or hospital, but the women were united in not letting her go.
Gladys then sat on the arm of a wooden chair and held Esi under the arms, supporting her against Gladys' thighs. She had me sit on the other arm to balance out and weigh down the chair. Amenuvor sat on a stool below Esi. After checking dilation again, Amenuvor massaged, rubbed, and manipulated Esi's abdomen. Her contractions were nearly constant by that point. Amenuvor sometimes pressed gently from both sides; she sometimes pressed downward from the top of the fundus. As the contractions became stronger all the women encouraged Esi to bear down. She groaned and strained, but complained that she was too tired. When the contractions would briefly cease, she flopped backwards into Gladys' arms and legs, obviously very weak. At this point Amenuvor started pushing on the abdomen and squeezing from the sides during contractions. This interaction went on for about half an hour. Esi continued to protest that she wanted to go to the doctor, which prompted discussion and argument among all the women. They told her to push harder, and sometimes they slapped her on the thighs.
At one point in the midst of all the arguing or discussion, I thought of how Carol Laderman described birth in Malaysia (in her book Wives and Midwives) as run by the laboring mother -- who dictates the pace, the activities she performs, the positions in which she places herself, the food or liquid she ingests, etc. I reflected for a moment on how that did not seem to be the case here where the five women (three of them over sixty years old) seemed to be clearly in charge. Esi was treated as a novice, and her request to go to the hospital was consistently denied.
Meanwhile, I was still acting as an anchor on the arm of the chair, Gladys was supporting Esi from behind, and Amenuvor was on a stool in front. Esi was trying to push, but also putting up quite a fuss (verbally) and continuing to plead to be taken to the hospital. At some point, and the timing and reason was unclear to me, Ama said, "Ok, let's go." She was speaking mostly to me. I asked, "To the hospital?" She said, "Yes." I went to get the car. Everyone in the compound was gathered outside Ama's house, with worried looks on their faces. When I returned to Esi's room to let them know the car was ready, Maggie smiled at me and said, "You wait. Just wait." Esi was now lying on her back on the bed. Maggie stood over her talking to her. Amenuvor gathered the items from her kit, packed them all into her plastic bucket and wrapped a scarf around the entire package. Amenuvor looked disgusted. Her face looked tired, sweaty, and she seemed rather angry or annoyed. Ama had left the room, but I could see her coming and going from her own room and dressing to go to the hospital. Gladys rummaged around pulling out various items from a purple basket, assembling cloths, baby clothes, a bottle of antiseptic liquid, a can of powder, etc. Grandma sat on her stool watching over Esi.
As Amenuvor and Grandma tried to help Esi get up from the bed, Amenuvor suddenly cried out that the baby was coming. Gladys rushed over. Amenuvor yelled for her red rubber mat to be spread on the floor, and for a cloth to be placed over it. Ama rushed in with a cloth. Meanwhile Amenuvor and Gladys lifted Esi up off the bed and down onto the floor, onto the mat and cloth. Less than a minute after Esi was positioned on the floor the baby's head began to emerge. Amenuvor kneeled down and held the crown of the baby's head. Esi pushed; the women yelled for her to push harder, and she did. The entire head came out, but the cord was wrapped around the baby's neck. Amenuvor immediately worked her fingers under the cord and manipulated it over the face. She also worked to wipe off the baby's face with a cloth, and she placed her fingers in the baby's mouth (clearing out some mucous). He started to cry as the shoulders and the remainder of his body emerged. Kwaku (Wednesday born boy) was born between 10:00 and 10:10 a.m. on April 20th, 1994.
At 11 in the morning I was called to a neighboring village where a TBA named Sena was attending to a woman in labor. The house was dark, without electric and the shutters on the windows closed tight. The delivering mother was pacing, walking from one room to another, a piece of avo (cloth) wrapped around her waist. Her body ornamentations indicated she was a member of a religious sect called Yeve: three cuts in her cheeks, the upside down V on her back, and three marks on each upper arm. As she paced, she held her lower back, and groaned. Her face was drawn, tired, and tense from holding pain. Sena explained to me that the woman, Ami, wanted to go to the hospital, but she didn't have money. She also explained that Ami already had 8 children and recently had 2 abortions. This was therefore Ami's 11th pregnancy.
Sena and I left Ami's house and visited several former clients. After an hour and a half we returned to check on Ami. She was still pacing. After washing her hands with soap and water in a basin she had previously set out, Sena examined Ami by inserting the fingers of her left hand into the vagina. She then brushed Ami's abdomen with a whisk to remove enu -- bad will which (according to local beliefs) was preventing the baby's birth. Sena turned to me and said it would be awhile before delivery. The two women discussed the possibility of her going to the district hospital and I agreed to drive the 30 kilometers in my car if they decided to go. As we left the house again Sena explained to me that one of the children was going to summon Ami's husband to see if they could get enough money for a hospital delivery. We waited at Sena's house and as the next couple hours passed, two women came visiting. Sena complained to them about Ami having too many children and they all agreed that she should utilize "family planning."
About 3:00 Sena went to check on Ami. When she returned she stated that Ami would not be going to the hospital: the husband had been consulted and he said there was no money; therefore the baby should be delivered at home. Sena said it would be another few hours before Ami would deliver and that I should go home, eat something, get refreshed and then come back. When I returned around 5 p.m. Sena explained that Ami had borrowed some money and she wanted me to take her to the hospital. We went to the house and loaded up the car with Ami's belongings: a bucket, a wash basin, a bag of cloths, clothes, etc. Ami's sister accompanied her and the four of us got in the car and set out.
We first went to the clinic about half-way between the village and the hospital (in Keta). Sena headed toward the living quarters of the government or public midwife. Ami, her sister, and I waited near the clinic door. Meanwhile a community health nurse-midwife was departing from the clinic but stopped to greet us and inquire about what was going on. I explained the situation and she said that the TBA should not be delivering when the woman has had more than 6 children. I recounted the discussions about money and the husband's role and explained that the TBA had no power one way or another over whether Ami could or would go to the hospital: it was about money. The community health nurse understood and sat down to wait with us for the government midwife. Sena returned and told us that the midwife was eating dinner, so we waited another 10 minutes before the midwife appeared and unlocked the clinic door.
The community health nurse and the midwife escorted Ami into an examining room. "First I'm going to retrieve the card," the midwife declared as she came out of the examining room and passed through another door. When she emerged from the file room she exclaimed disdain at the fact that Ami had only been to the clinic one time during the whole pregnancy. She re-entered the examining room scolding Ami for the fact that the last time she had been in was 4 months ago. She closed the door. Sena and Ami's sister immediately broke into a heated but whispered discussion over how Sena had told her to go to the clinic for pre-natal check-ups but the sister said there was no money for transport, medicine, or time away from the farm.
The midwife emerged from the examining room and declared that Ami must go to the district hospital as this was her 11th pregnancy. "Why did they wait so long to get her here?" the midwife wanted to know. "She's had 8 children and two abortions. She should have gone right to the hospital when labor started. Here, read what I've written." And she thrust the green card into my hands. Labor pains began 4 a.m.; the biggest complaint was pain in the thighs; presently 3 fingers dilated and would probably deliver around 7 p.m. The community health nurse told the midwife what I had said about Ami wanting to go to the hospital but not having money. "But 11 pregnancies?" the midwife retorted. "It's TOO MANY children." As the midwife filled out referral papers she told me that she was going out and would ride with us half-way to the hospital. I had already offered the community health nurse a ride since her house was near the hospital. We waited for the midwife to go back to her quarters and change clothes, and then we were on our way.
By the time we reached the hospital it was almost 6:30. Ami had been in labor for over 14 hours. The community health nurse led the way into the maternity ward and introduced Ami to the hospital midwife-in-charge. As the midwife took the referral cards from Sena and Ami's sister, a discussion erupted about "sheets." Two hospital nurse-midwives scolded and admonished the sister and Sena for not bringing sheets for the bed and old cloth (rags) to use during delivery. The community health nurse tried to "run interference" explaining that they may not have known, or in the haste of getting ready they may have forgotten. But the midwife-in-charge continued to harangue about the fact that they didn't bring sheets. "The TBAs should know! If they refer cases to the hospital, they should instruct the women about hospital rules and regulations," she declared. After the midwife left the room the community health nurse reminded me of an on-going discussion she and I had been having about how the regular midwives were not trained in community health practices and so they did not know how to communicate or deal with people from the villages. She then said goodbye and I sat down on a bench to wait.
Sena came and went from the hospital several times. She got money from Ami's sister (from the "knot" in the sister's cloth) and went out to purchase various items: a towel, razor blade, a bar of soap. I sat next to Ami's sister and watched the activity in the waiting room. The television played CNN on which was a broadcast about Michael Jackson and his marriage to the daughter of Elvis Presley. A nurse entered the waiting room and the midwives on duty told her that they presently had a case where it was the woman's 11th pregnancy. The third nurse howled. Ami's sister sat stone faced acting as though she had not heard this exchange.
As we waited Ami emerged from the labor room, barely able to walk, with avo (cloth) wrapped only around her waist, and the sister jumped up to help her go to the bathroom. The nurses yelled, "Where are your shoes? Put some clothes on." The sister let go of Ami's arm and hastened to the canvas bag and bucket containing personal belongings. She pulled out a pair of sandals and a cloth and took them to the toilet. When Ami emerged from the toilet she wore both shoes and a cloth around her top. With her sister's help she slowly hobbled across the waiting room and back into the delivery room.
A few minutes later a woman orderly in a red checkered uniform emerged from the delivery room wearing long, heavy rubber gloves, and informed the nurse-midwives that they should come. The one in charge whipped off her hospital gown and handed it to me to put on. When we entered the Labour Room all three of us took off our shoes and stepped into heavy white rubber boots. Ami was lying on an examining table in one room, flat on her back, her legs extended. The two nurse midwives rushed around getting the second room ready for delivery. From a bucket filled with antiseptic liquid they pulled metal pans, clamps, scissors, etc. and lined them up along a metal table.
The midwife in charge yelled several times for Ami to come into the second room. She attempted to get up, but couldn't. I went to help her. I held her upper back and raised it up, then helped her swing her legs over the edge of the table. Ami was very small and thin. Once she got her feet on the floor she was able to walk, though very slowly. I followed her into the other room. She headed toward the table they had prepared for the delivery: a metal, adjustable contraption that looked confusing even to me. As Ami climbed the wooden steps leading up to this delivery table I could tell that she did not know what direction to place herself. I instinctively lurched forward to go and help her but then stopped myself thinking that I should probably remain an observer in this setting. Sure enough Ami began positioning herself backwards and the midwives yelled at her. Ami struggled to get herself down off the table, holding her lower back, her face cringing with pain, and then back up again facing the other direction. Both midwives stood watching and ordering that Ami move more to the left or right accordingly. She struggled to push herself down closer to the edge of the table, adjusting herself to their directions.
Finally Ami was situated for delivery. The midwives resumed assembling the sterilized gadgets and then the midwife-in-charge checked Ami's dilation. Soon after the baby's head appeared and the birth itself went quickly. The baby let out a small cry. The midwife clamped the umbilical cord in two sections, then cut it with a scissors between the two clamps. She then handed the baby to the other nurse who proceeded with suctioning the mucous and fluid from the baby's nose, mouth, etc., and then weighing and wrapping the baby in cloth. The child was a girl and weighed 5 1/2 pounds. Meanwhile, the midwife-in-charge attended to Ami who had to push and bear down before the placenta was expelled. The midwife examined the placenta for rips or tears and then checked Ami's cervix for possible damage. As they cleaned up we chatted and I informed the midwives that this is the first time Ami had ever delivered in a hospital. At first they did not believe me since her chart indicated she had 8 children. I explained that the previous 8 were all born at home. "Oh, well that's why she didn't know how to get up onto the table," the midwife commented. Meanwhile Ami was still bleeding quite a bit, but again struggling to get down off the table and out of the delivery room. Once outside her sister and Sena helped her to a bed in the maternity ward. After saying goodbyes to the midwives and Ami and her sister, Sena and I left the hospital and drove back to the village. Sena was not and would not be paid for the nine hours she had spent away from her main source of livelihood: farming and weaving of baskets. Furthermore, even if she had delivered the baby, there was a more than 50 percent chance she still would not have been paid.
One of the striking similarities between Esi's and Ami's cases is the fact that both women wanted to deliver at the hospital. The notion that childbirth should occur in the hands of specialists (or should be "managed by professionals") has definitely taken root in many places in rural Ghana, even if in most cases it remains an unrealized ideal. While Ami sought professional help only once for prenatal care, she wanted to be in the hospital during the birth itself. Both Esi and Ami encountered opposition to this desire within their families, which points to a second issue concerning the locus of responsibility and control of childbirth.
Esi's case reveals the collective and familial nature of the decision making process about childbirth, as well as certain poignant aspects of social change in the Anlo area. As an individual, Esi would have chosen to go to the hospital and she made this preference known, but the outcome of her delivery was clearly influenced and shaped by the female elders of her lineage. While the elders were opposed to the biomedical approach, Esi's mother (Ama) did not render an opinion about the hospital during the heated debates. Like many Anlo-speaking people, she resides in that conflicted and liminal space where tradition and modernity coexist. As her daughter implored them to take her to the hospital, Ama's passivity served to support the ideology and practice of the elders; when she eventually told me to get the car ready to transport Esi to the hospital, her decision seemed to support the medicalization of birth. In this particular case, however, the protestations and procrastinations of the TBA and the lineage elders had worked to control how and where Esi's delivery took place. They had succeeded in delaying the decision long enough for the natural process of birth to occur rather than allowing a (bio)medical intervention. The older women deeply believed that if Esi had gone to the hospital, the baby would have been delivered by "cutting her open."
In contrast to the fact that financial constraints were not mentioned as a reason Esi's family did not want her to deliver at the hospital, money seemed to be a critical factor in Ami's case. While I was not close enough to Ami's household to be privy to their internal discussions and negotiations, it seemed that Ami's husband deemed the biomedical setting to be too expensive. No objection to the TBA's assistance was expressed, although she too would have asked for compensation. In addition to the price difference (3000 cedis for the TBA; between 10,000 and more than 20,000 cedis at the hospital) is the fact that the hospital required payment in advance of any service while the TBA sometimes spent years trying to collect her fee. Ami finally obtained the money without the assistance or approval of her husband, and with the support of her sister plus her birth consultant (Sena the TBA) and the use of my car for transportation, she overrode her husband's authority and delivered at the hospital. Whereas Esi was in her early twenties, Ami was about forty years old which may account in part for Ami's comparative assertiveness. Not only was Esi female, she was also young -- making her subject to the authority of her elders. After Esi's baby was finally born, the child's father brought a bottle of liquor to pour the requisite libations. In the process of administering the baby's ritual first bath, pouring libations, and performing several other rites, Amenuvor (the TBA) spoke sternly to Esi and the child's father. She chastised Esi for putting up such a fuss about going to the hospital where they certainly would have "cut her" to get to the baby, and would also have failed to perform the necessary rituals to remove enu. According to Amenuvor, without eliminating the bad will causing the enu, Esi and the baby might have died.
Both cases illustrate the conflict over whether birth belongs under the jurisdiction of the kinship system or health care institutions. In Esi's case, the point of contention was largely cultural: the family objected to the procedures that were likely to be used in delivery, and they believed they would be placing Esi in danger by sending her to the hospital. In Ami's case, the point of contention was largely economic: the biomedical approach seemed beyond their means, certainly during the pregnancy itself, and up to the last stretch of the labor and birth. The TBAs are supposed to function (to a certain extent) as arbiters between these two domains. For example, they are supposed to refer women to the hospital who are primigravida (pregnant for the first time) and grande multipara (a woman of high parity or having delivered many times). Indeed, Esi had delivered her firstborn at the local clinic, and Amenuvor perceived this second delivery to be fairly routine. If the baby is indeed transverse or sideways (as Esi's baby might have been), the TBA is supposed to send her to the hospital or clinic. But this is a point of contention, as many TBAs believe they are experienced at dealing with a variety of difficulties during labor. Since Ami was grande multipara, Sena was willing to "refer" her to the hospital, but the referral tactic proves useless when the client does not have the means to pay. Sena, therefore, considered herself "on-call" (so to speak) for the entire day, believing that Ami was in need of her assistance. In the end, however, Sena's services were completely overshadowed by the dominance and cost of the health care institution: Ami would spend all her funds on the hospital bill, and Sena would not get paid. Some TBAs are more accepting of this predicament than others, stating that most of their "clients" are relatives making the kin-based obligation to assist supersede the monetary aspect of their role. Others have become increasingly irritated by this problem. For instance, Amenuvor (from a neighboring village) was called to Esi's house despite the fact that Agbelidu's official TBA lived only a few compounds away. This was Amenuvor's second delivery that month within our compound. A year later Amenuvor complained to me that Maggie never paid her even one pesewa, and Esi's family had only delivered half of the 3000 cedis owed (roughly US $1.50 out of $3.00). These families are not Amenuvor's immediate relatives, which illustrates the paradoxical position held by so many TBAs. They are neither a part of the public health system which functions in purely "cash and carry" terms; nor are they simply relatives who would be compensated through kinship based conventions of reciprocity. At Esi's birth Amenuvor was neither a "professional" nor one of the lineage elders overseeing the return of one of their beloved ancestors; Sena functioned for Ami as a free consultant, while simultaneously missing an entire day's work. So while the TBA program may sound like a simple and straightforward way to improve the nation's child survival and safe motherhood rates, it actually exhibits many of the intense problems people face because of rapid social change as well as the struggle for control over childbirth and reproduction.
Control over reproduction, and the topic of family planning, is yet another issue highlighted by the cases above. If limiting the number of one's children is so important at this point in history, why was Ami having a ninth child? While I do not know Ami's specific reasons for going through with this particular birth, two general explanations are likely to pertain. First, as long as economic conditions do not change in rural Ghana, it is still advantageous to have large families of six children or more. Secondly, Ami's reproductive history demonstrated that after delivering eight children she had two abortions, which indicates that she was interested in controlling her births, but points to problems of limited access to contraception.
While in Ghana I often asked people who had merely two or three children, or people who had a fair amount of education and were considered middle class, why they thought rural people had such large families. They were usually amused by my question and often responded with the quip, "Villagers have nothing else to do after dark!" As simplistic and pejorative as this comment might sound, a fair amount of research points to essentially the same conclusion. In a context in which there are few income generating opportunities and virtually no consumer goods available, children are considered wealth. That is, in situations of poverty where there is little chance to make money and hardly anything on which to spend money, children are a major focus of energy and attention. When economic development begins to occur, one of the effects is an "increasing competition provided by rising consumption standards" or "an increasing flow of new goods and new ways to spend money, which can substitute for expenditures on children" (Murdoch 1980:24). In the absence of such economic development, however, the "high economic value of rural children [such as] in the African context ... is understandable. Rural Africans spend long hours farming and performing other household activities. Children contribute labor in cropping, livestock herding, fetching water and fuelwood, and child rearing" (World Bank 1989:69).
Three factors may come into play as parents determine family size: consumption benefit, labor and/or income benefit, and security or old age benefit (Murdoch 1980:21). The consumption benefit motivates parents simply by virtue of children being desired because of the emotional pleasure they bring. The labor or income benefit corresponds to the idea cited above: children in poor countries, particularly in the rural areas, carry out critical chores that contribute to the income generating activities of the entire household. Furthermore, the "labor and income benefits from children increase with their age and are reaped as long as they are associated with the parents' household. In extended families this may be well into adulthood. For example, older children who have left the household and migrated to the city often send home cash" (Murdoch 1980:22). Finally, in a context with a minimal to non-existent social security system, children are a major source of sustenance and security in old age -- in the form of cash, food, shelter, assistance in emergencies and medical crisis. Children, therefore, are wealth for rural Ghanaians, and until an alternative economic system is available or put into place, families such as Ami's will not be motivated to limit their children to just a few.
After having eight children, however, Ami's two abortions seem to indicate at least an interest in practicing "family planning." When a woman such as Ami decides that indeed she wants to begin limiting the number of children she delivers, what are her options and what are the obstacles preventing her from exercising her choice? Several significant studies have been carried out in Ghana which raise these precise questions (e.g. MOH 1990, 1991, 1992a; CBS 1983; Phillips & Greene 1993; GRMA 1990). One conclusion reached points to two main types of obstacles blocking rural Ghanaians from utilizing family planning: "The first category is the wide body of rumors, misconceptions, exaggeration and misunderstandings that exist in the community resulting in fear and rejection of Family Planning methods. The second category is related to low geographical accessibility and socially inappropriate setting of the family planning services in rural areas" (MOH 1992a:iv). This same study revealed that over three fourths of rural Ghanaians surveyed are aware of methods of birth control and where they can obtain modern contraceptive devices, and 35% of married women in Ghana desire to control their births, but only 5% actually utilize modern methods of family planning (MOH 1992a:1). Why the large gap between desire and actual use in Ghana in general?
The first problem revolves around education. While modern methods of contraception are "known" or "recognized," little is understood about how they work and the ramifications of using them. For instance, the term "family planning" itself is misconstrued to mean a variety of things including sterilization, spacing children, halting conception, and even abortion. In addition, many people are unclear about side effects contraception can have on the body, and rumors and exaggerations are abundant. For example, people believe that birth control methods in general can cause permanent infertility, dizziness, abdominal pains, and irregular bleeding; that IUDs can stick in the growing baby's body; and that using contraceptives can even lead to AIDS and death (MOH 1992a:11). So, even those who would like to limit their children often fear the adverse reactions that can result if they utilize modern, biomedical types of birth control.
A second problem revolves around widespread beliefs that using contraception goes hand in hand with anti-social behavior such as promiscuity, prostitution, and general immoral behavior (MOH 1992a:12-13). Such perceptions within a community cause individuals to be reluctant to use family planning, or if they still are motivated to use it, there is a strong need to keep this information secret or confidential. In rural communities where most transactions occur on a face-to-face or personal basis, keeping such information concealed is extremely difficult. One study demonstrated that many rural Ghanaians do not go to TBAs for birth control because they view these people as "socially gregarious individuals who talk openly about who is using family planning" (Phillips & Greene 1993:57). Indeed, in the course of my own fieldwork TBAs have reported that they do virtually no business in providing birth control devices to clients; and informal interviews with members of the community produced complaints about not even being able to obtain contraceptives at the district hospital because of nurses gossiping and spreading rumors.
In addition to the problem of confidentiality, availability in rural areas is yet another problem. "Contraceptives appear to be extremely scarce in rural communities. ... in most cases we estimate that a client would need a one or two hours journey (using local transport) to reach a family planning facility in one of the major towns" (MOH 1992a:13). And yet, research indicates that "villagers are not prepared to travel further than 5 to 10 miles to obtain family planning services" (MOH 1992a:14).
So, even when a rural woman wants to utilize contraception in planning, spacing, or inhibiting births, studies in Ghana show that three main factors exist as obstacles: fear of adverse effects, lack of confidentiality and the potential negative reputation, and scarcity or lack of availability. Finally, while the following issue is not directly contributing to a minimal use of family planning in Ghana, it is a factor to consider. Rural communities often express frustration that the government stresses family planning more than it makes an effort to deliver general health care services to their areas (Phillips & Green 1993:57; also MOH 1992a:16). People complain that the government pushes birth control more than general well-being, and they would rather see improved basic curative services rather than so much emphasis on family planning.
This paper focuses on the social context of birth and specifically explores the role that traditional midwives play in rural contexts. The ethnography demonstrates that many rural Anlo-speaking people are ambivalent about whether or not childbirth and reproduction should be treated as a medical phenomenon, and TBAs in this area therefore hold a very paradoxical position. The state (more specifically the Ministry of Health) has enlisted the assistance of traditional midwives to promote birth as a medical event which should be "managed" by a specialist. "Routine" births can be handled by TBAs, but complicated pregnancies and deliveries should be "referred" to professionals at the district hospital or a local clinic. While many rural people accept this perspective, and aspire to deliver their babies in a biomedical setting, in reality this is achieved by very few. Most births still occur at home and are attended to by relatives usually made up of predominantly female lineage elders. Economic factors remain a major reason for the persistence of home births since biomedical births and biomedical contraceptives are beyond the means of most rural people. TBAs are not part of the "cash and carry system" of biomedicine so they often go unpaid, leaving them in a vague position which they themselves find difficult to understand.
In addition to financial factors, however, many cultural and political issues also contribute to the persistence of home births. There remains a struggle for control over whether well-being and birth is a family concern or a state concern, and while rural people do not necessarily think about it in these terms they do express frustration over the government's seeming preoccupation with limiting the numbers of children compared to improvement of the overall status of their health. A strong distrust and suspicion exists for public health personnel so that births with not only relatives but with non-trained or non-TBA midwives (afeme vixela) continue to outnumber those managed by professional practitioners in the biomedical domain. Childbirth thereby becomes a reflection of the larger problem of conflicting values, and even within families such clashing perspectives often play themselves out in the negotiation of where and how a woman ought to give birth. TBAs therefore hold a somewhat pivotal and paradoxical position at the cross-roads between old and new or where tradition and modernity coexist. On one hand, TBAs fit some of the specifications of health care professionals: they have had some formal training, have a great deal of practical or "clinical" experience, they possess "authoritative knowledge" about pregnancy and birth, and they have a supply of items useful in the process of delivery. For these reasons, they have earned a certain reputation as a "specialist." On the other hand, they are simply women in the village related by blood and marriage to many of their "clients." They do not wear uniforms which demarcate other employees of health care institutions, and they do not (as a rule) have a clinic or a delivery space. They are aware of and actively perform many old Anlo rituals (such as removal of enu, a ceremonial bath, burial of the placenta, etc.) discouraged by those who represent the more "modern" approach. And in a technical sense they are not "specialists" at all, but like most villagers they perform multiple economic activities (including fishing, farming, basket weaving, or marketing) in addition to their service of delivering babies. TBAs have therefore not come close to achieving their potential as part of the local solution to improving child survival and maternal health. This leaves us with a number of questions such as whether or not the biomedical model is appropriate for normal states of pregnancy and birth. Does reproduction and childbirth really need to be managed by professionals? In the 21st century, where should a nation such as Ghana place its limited resources: dealing with the reality of deliveries in the home, or pushing harder to increase hospital births? This paper has shown that TBAs remain an underutilized and undeveloped possibility for a kind of childbirth which falls somewhere in between.
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