Experiences of women receiving reproductive health services from male midwives: a qualitative study in Bole District, Savannah Region of Ghana, West Africa

¹Department of Mental Health Nursing, School of Nursing and Midwifery, University for Development Studies, P.O. Box TL 1350, Tamale Northern Region, Ghana, ²Department of Preventive Health Nursing, School of Nursing and Midwifery, University for Development Studies, P.O. Box TL1350, Tamale Northern Region, Ghana, ³Ghana Health Service, Kintampo Municipal Hospital, P.O. Box 192, Kintampo Bono East, Ghana, ⁴Department of Paediatric Nursing, School of Nursing and Midwifery, University for Development Studies, P.O. Box TL1350, Tamale Northern Region, Ghana, ⁵Department of Midwifery and Women´s Health, School of Nursing and Midwifery, University for Development Studies, P.O. Box TL 1350, Tamale Northern Region, Ghana

^&Corresponding author
Mubarick Nungbaso Asumah, Ghana Health Service, Kintampo Municipal Hospital, P.O. Box 192, Kintampo Bono East, Ghana

Introduction    

Reproductive health is people's ability to have a satisfying and safe sex life and the capability to reproduce and the freedom to decide if, when, and how often to do so [1]. It is vital to have competent assistance during childbirth to ensure a successful birth for both the mother and the infant [2]. The training of experienced birth attendants is receiving more attention across the world as a strategy for lowering maternal and newborn death rates [2]. Midwifery from its inception has largely been acknowledged as a female profession [3]. Men were barred from becoming nurses as a result of the reforms instituted by Florence Nightingale, the creator of modern nursing [4,5]. Because of modernization, an increasing number of men began to enter the profession of midwifery in the twentieth century [6]. Male midwives are becoming more popular, but their acceptability is not universal [7]. Some argue that males should not be allowed in the birthing room since they have never experienced childbirth [8]. There is a misconception that delivery is beyond the capabilities of men [9,10]. When the topic of males in midwifery comes up, it typically elicits puzzled expressions. These discussions frequently result in the universal conclusion that males should not be in this field at all [11]. Male involvement in midwifery practices is a concept that is not fully accepted even among midwives [12]. On the contrary, midwives call on and involve male doctors in care for their patients forgetting that they are males [13].

It is common knowledge that the profession of midwifery is dominated by females, and the challenges and complexities of this have been explored at length [13]. However, male midwives are highly discriminated against not just by clients, but also by female members of their profession, which is found to be unfair [8,10]. Many believed that a man would not be able to understand what a woman is going through during pregnancy, labor, and puerperium while some found men's motives suspicious [10]. The existing placement of midwives does not take into account the preferences of pregnant mothers. In Ghana, most midwives refuse placement in rural areas. Also, the midwife-to-patient ratio is woefully inadequate [14]. The government of Ghana through the Ministry of Health recruits and posts qualified midwives across the country. However, midwifery is supposed to be client-centered, thus, rendering services according to the preferences of the expectant mother. Unfortunately, expectant mothers' preferences for midwife gender have not been explored and documented for midwife deployment in Ghana. Also, it is common knowledge that the phenomenon of male midwifery is quite new in Ghana. As such, the expectation of the male midwives varies from one community to the other. Whilst it is crucial to explore the expectation, experience, and preference of expectant women on male midwives to bring out the challenges for further interrogations, as far as we know, none of such studies are found in Savannah and Ghana at large. This study, therefore, seeks to explore the experiences of women receiving reproductive care from male midwives in Ghana.

Methods     

Study setting: the study was conducted in Bole District which lies between Latitude 9°03N and Longitude 15°E and 2°04 W. There are eight (8) health centers, two (2) of which are private, one district hospital, and nineteen (19) CHPS compounds Community-based Health Planning and Services (CHPS). There are two (2) doctors in the district. This indicates that one of the district's two doctors serves a population of more than 37,576 people. There are 30 midwives in the Bole district of which three are males. The projected 2021 population of Bole district based on the 2010 population and housing census is 87,656.

Study design: the study used a descriptive exploratory study design using the qualitative approach. This design allowed the researchers to explore the expectations and experiences of the participants upon receiving reproductive health services from male midwives.

Sample size and sampling technique: the study targeted women of at least 18 years leaving in the Bole District who have received services from male midwives. The participants were also those who could speak English or Gonja. A purposive sampling technique was used in this study to select the participants. The researchers recruited 15 participants for face-to-face individual interviews. The sample size was determined when saturation was reached.

Data collection procedure: formal permission was obtained from the district directorate of health services to conduct the study in two health facilities where there are male midwives. The researchers then visited the two health facilities and met with the nurse managers to explain the study to them. The midwives in the health facilities facilitated the process of meeting the potential participants. The researchers met the participants after they had finished receiving the health services for which they came to the hospital. The participants were allowed to indicate the date, time, and venue for interviews. Most of the interviews were conducted at the participants' homes, though a few were done in the health facilities. The interviews were conducted in English or Gonja using a semi-structured interview guide developed based on the purpose of the study. Permission was obtained from the participants to audio-tape the interviews. The interviews that were conducted in English were transcribed verbatim, and those conducted in Gonja were transcribed based on their meaning. An expert in Gonja was contacted to verify transcripts that were in Gonja and confidentiality was ensured in the process. The interviews lasted between 25-40 minutes. The data was collected between May to July 2021.

Data analysis: the data were analysed using thematic content analysis (TCA). Thematic content analysis allows the researcher in grouping the data into a similar theme that provides a voice or real portrayal of the data set [15]. The transcribed data were checked for accuracy and read severally to under the perspective of the participants. The transcribed data were coded individually by three of the researchers, who then had several discussions to generate themes and subthemes.

Ethical consideration, registration: the ethical approval was obtained from the University for Development Studies Ethical Review Board. Also, permission was granted by the District Health Directorate for the study to be carried out. All participants signed written consent. Respondents had the liberty to withdraw from the study at any point without any repercussions. Anonymity was maintained by representing participants with numbers such as participant one, participant two, etc.

Results     

Socio-demographic characteristics of participants: all the participants (15) were females who were married and practicing monogamy. Their ages were within 22 to 34 years. The majority (9) were Muslims whereas six (6) were Christians. Except four (4) who were not working, two (2) were seamstress and the nine (9) were traders. Four (4) of the participants had attained secondary level of education, three (3) had attained primary education and eight (8) had never been to school.

Expectations of women receiving reproductive care from male midwives: this theme outlined the expectations of women receiving reproductive care from male midwives. Thus, the women expect good health care delivery, kindness, males´ midwives cannot understand women and male midwives should work with female midwives.

Good health care delivery: the participants expressed their emotions when they first heard that male midwives were been posted to the area. Some of them were happy because they had gotten health care providers in their community even though they were males. "I was happy and surprised when I heard there are health care providers in our community to help us deliver even though they were males" (participant 1). Participant 15 also has this to say on the expectation from the male midwife "I was surprised, but I was expecting the new male midwife to be at post all the time and also help in all aspect of our pregnancy and childbirth to avoid losing miscarriages, stillbirth and babies" (participant 15).

Males will not understand women: the majority of the participants thought because a man neither gets pregnant nor deliver, he would not understand the pain and difficulties women go through during pregnancy and childbirth. Participant 4 narrated her story as “First, we thought man does not either get pregnant or deliver, so he might not understand us, but he is good. He delivers excellent services” (Participant 4). Again, participant 8 has this to say: "For us, we thought it was only females that can conduct delivery. We were therefore surprised to hear that this time it would be a male that would be conducting the deliveries in our community" (participant 8).

Kindness: the women were expecting some good attitudes from the male midwives. They expected the male midwives to show them kindness, sympathy, and patience "Aside from taking good care of us. We also expect him to be patient, understanding and should not shout at us during ANC visits or our hospital visits” (participant 5). Again, “We were expecting him to care for pregnant women and our children and I think he is doing exactly that” (participant 14).

Male midwives should be with female midwives: these are the expectation that the community women had in mind. For instance, even though they heard that midwives were coming into their community, they were expecting female midwives. “We thought he was coming with a female midwife, but in the time we realized he was alone. It is just recently they brought a community health nurse to come and work with him. We would have been happy if there are two or three female midwives in addition” (participant 4).

Experiences of women during their encounter with the male midwife: this theme explains the experiences of women having received care from male midwives. The participants indicated that male midwives are good at their work but portray poor attitudes. The participants also indicated that they were feeling shy as women receiving reproductive health services from male midwives.

Good at his work: the majority of the respondents expressed confidence in the work of male midwives. They explained that the male midwives were patient and soft-spoken. They recounted very good remarks on the quality of care given by these male midwives. Participant 1 expressed her experience as "For me when I went there, he took good care of me with care. The drugs he gave me solved my health problem. He took his time to educate me on my pregnancy and answers my questions in a simple manner" (participant 1). The participants also testified that apart from doing excellent work, he is also patient and does not shout at them except those who were recalcitrant. "He has patience more than some of the female midwives. He doesn't shout at us except those who are disobedient to him especially if he tells you to push and you refuse during labor" (Participant 4).

Shyness of recipients: other women did not like the idea of male midwives providing services to women. They were feeling shy because their nakedness would be seen by another man. "We didn't want to go there even when we were in labor. But two or three women went and came back to testify that he was good" (participant 13). Another participant testified how her shyness tends to happiness particularly when she noticed that it is a male midwife that would be conducting the delivery, somebody that is not the husband. “I was very shy that a male who is not my husband would deliver me. But I became happy when he delivered me. He would say "sorry" till he finishes the delivery” (participant 8).

Poor attitude of male midwives: the participants explained that when they are to deliver at the hospital, the midwives require that they bring certain items. Male midwives were cited as still demanding the items even when the woman delivers at home. The male midwives in an attempt to ensure that they collect the items will not record in medical records. "Even if you deliver in the house, and he comes to attend to your baby, he has to take the items that one would have bought if she was to deliver in the health facility" (participant 6). How the male midwife interacts with women during the postnatal clinic was narrated as very appalling and contrary to what a midwife will do. A participant indicated that the male midwives ask their patients to go back home because they were late. "He turns mothers away when they come late for child welfare clinic (CWC). If you get there at 8 am, you are in trouble. For me, I think even if you go to CWC at 10 am, you are not late. If I come always, and you send me home because of lateness, what will happen to my child." (participant 7). Another participant continued how this unpleasant experience has affected her child welfare clinic attendance. She has not been able to attend the child welfare clinic regularly. "For the past two months, my child has never been weighed. Whenever I'm late, I don't send my baby because he would not attend to us" (participant 8).

The perception of women about male midwife: the theme explains how the participants' perceived the concept of male midwifery. The participants compared the male midwives to that of their female counterparts. The perception of participants was centered on three main areas which include cultural/religious beliefs, preference for female midwives, and perceived negative attitude.

Cultural/religious beliefs: the culture or religion may accept or may not, or the public may accept or frown at patronizing a male midwife attending to them. Some participants indicated that in their religion males are not allowed to touch a female. However, the participants indicated that receiving health services from a male is considered a special situation that was acceptable. "Our culture says no man can touch me. But if it is about a delivery, it is between life and death so another man can touch me, and nothing will happen. If I am not pregnant or sick and he touches me, there will be a problem" (participant 1). “According to Islamic principles, a man who is not your husband should not see your nakedness. The culture in this area also says the same thing that it is a sin for a man who is not my husband to see my nakedness. However, it is not a sin for a male doctor or nurse to see your nakedness if he/she is providing health care” (participant 5). Some participants narrated that Islam forbids that a man delivers another man's wife. In some instances, some women are told by their husbands that when they go to deliver in the hospital, they should not allow a male healthcare provider to attend to them. “Our religious leaders said it was not good for a man to deliver another man´s wife, therefore, they would not agree for that to happen. Some of the men do not want another man to see their wives´ nakedness and so they tell their wives to make sure is a female midwife that would attend to them” (participant 2).

Preference for male midwives of the female gender: some women expressed the need to add female midwives to the male midwives so that women would have the option to choose who should attend to them. They accepted that for every work there is gender balance therefore females should be included in the rendering of maternal health services where males are posted. A participant narrated her story as follows; "Every work there is mix gender. They should add female midwives so that if a woman goes to the facility, she could be attended to by a female counterpart. My next pregnancy, I would like a female midwife to attend to me. This is because a female midwife is a female, and I am also a female, so she would understand me better" (participant 3). Participants wish they would be attended to by a female midwife in the future. "Our culture knows that it is a female that conducts delivery, but when we saw he was a doctor we didn't have any problem. However, I prefer a female midwife to attend to me when I get pregnant because our culture permit females to be midwives. That is what has been happening since the olden days" (participant 6).

Perceived negative attitude: the participants referred to stories of how men sexually harassed women. The participants never forgot how some women have been raped at some health facilities. The participants never forgot any of these when they heard that male midwives were coming into their community. Participant 4 expressed her feelings as “We heard that male midwives were coming to our communities through the "kongkon" beater. We were like eii how come? We had heard that if a male midwife delivers a woman, the male midwife can rape the woman. We were terrified. But they said some were good. So, we decided to give him a try” (participant 11).

Discussion     

The study examined the experiences of women receiving reproductive health services from male midwives. The participants indicated that men do not get pregnant neither do they give birth hence they would not understand women when it comes to childbearing. The women were expecting that men would not understand the pain they go through during labor because they have and would never experience such pain in their lifetime. Participants also narrated male midwives are patient and do not shout at them except recalcitrant women. This is related to a study in South Africa where almost all postpartum women (97%) thought male student nurses and midwives handled them with decency and respect in comparison to female counterparts [16]. Women expressed their experience about the good work of the male midwives. According to the women, the male midwives were very good in their work to the extent that they are nearly better than their female counterparts. This is consistent with a study that reported that a female midwife who was attended to by a male midwife at birth said that she admires male midwives´ techniques so much that she strives to emulate them in her work [17]. The study showed that the midwives demand items even for delivering at home and refuse to attend to women that come late to the health facility. Though this was reported among a few women the negative impact of this on the utilization of services rendered by male midwives is high. Women and children who are refused care may resort to other means of seeking health care which could make the situation worse. This is corroborated by a study in Ethiopia where women are aware that their rights are being infringed as such they do not go to the hospital when they are sick [18]. Also, delivery by a skilled birth attendant is encouraged [19,20]. However, the demand for items such as soap, parazone, and sometimes money, etc. may endanger the patronage of a skilled birth attendant, especially among poor women.

Some participants expressed how shy they felt when they are attended to by a male midwife. This is consistent with a study that reported that 69.7% stated that they are shy towards male midwives during service [21]. Another study supports our findings where approximately half (49.9%) of the women described the idea of being cared for by a male nurse as “uncomfortable”. Many participants believed that their permission should be obtained before being assigned to a male midwife [22]. Our findings show that some women naturally preferred female midwives to attend to them than male midwives. It all bored down to how they were uncomfortable exposing their private parts. Women with this perception thought that men should not be in midwifery. This is supported by a study that revealed that most women often ask questions such as: why would any man want to be a midwife? What could the interest or motivation be? Why don't the males leave midwifery practice alone for women? [10]. The finding of the current study is consistent with a study where participants prefer not to be attended to by male student midwives during pregnancy and labor [16]. Similar views were elicited by Shavai & Chinamasa [8] where most expecting mothers prefer female midwives. Again, participants argue that it would be more comfortable dealing with female midwives when it comes to dealing with their reproductive organs than with male midwives and so insists that males should not be allowed to train in midwifery institutions [22]. Also, Bolsoy et al. [21] revealed that 98.4% of participants would prefer a female midwife to attend to them.

Many religions and cultures in the Ghanaian context frown on a man viewing the nakedness of another man's wife. The values and norms were explicit without giving a condition or circumstances by which this value can be violated. Participants were not forgetful about these values and norms, and expressed that their culture and religion speak against a man looking at the nakedness of another man's wife. This finding is consistent with a study that reported that mothers from rural areas preferred female midwives, with culture and religion being a contributing factor to this choice [16]. Participants also expressed that their husbands also support the view of the culture and reject male midwifery. This is not different from a study that revealed that in Somali culture, men are also averse to male midwives intimately touching their wives [23]. Participants expressed their fear towards the opposite sex, especially when they are to work on women's private part. These women were cribbed with fear of being raped or sexually abused by male midwives based on what they had heard from elsewhere. This result is consistent with a study that revealed that postpartum mothers, preferred care by male students' midwives; they were viewed to be respectful, sympathetic, and caring; however, they discussed their fears of midwifery practice with mothers [16]. This study is the first to explore the experiences of women receiving reproductive care from male midwives in the region. It, therefore, provides essential evidence on the contributions to the concept of male midwives and what areas should be improved.

Limitations: the study involved all two facilities in which male midwives were in the selected district. However, it will be difficult to generalize the findings to other districts where male wives work currently. Also, the study employed a purposive sampling which might be prone to selection bias.

Conclusion     

In all, male midwives are doing well in the midwifery profession. Problems such as women being shy about their nakedness and the influence of religion and culture have made midwifery practice among males difficult. There should be regular in-service training for male midwives to equip them with the necessary techniques in handling women and to win their trust. Although the idea of men in midwifery is not universally accepted, the study recommends proper education and training, public awareness campaigns, and ensuring that expectant women's right to choose the sex of their midwives. There should also be public education on the need to accept male midwives in the rendering of reproductive health services.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors were responsible for the study. They also contributed intellectually, and proofread and approved the final version of the manuscript.

Acknowledgments     

We are indebted to the participants who voluntarily decided to share their experiences to enrich this research. All the authors have read and agreed to the final manuscript.

References