You might have never seen a male midwife before in your life, but they do exist. Midwife Without Borders takes you across gender and national borders to Ghana, in this first part of a series on (male) midwifery across the globe.
Skilled birth attendance and good pre- and perinatal midwifery care are key in reducing maternal and neonatal mortality and morbidity rates. One of the measures the Ghanaian government took to increase the number of midwives is to allow more people into the midwifery training schools, “including piloting male students into selected midwifery training institutions”. Having started to offer free consultations to pregnant women and mothers with young children, put a considerable strain on Ghanaian hospitals, which are struggling to keep up with the growing demand in terms of staffing and supplies. Allowing male midwives was thought to be part of the solution to this problem. After only a few years however, the Ghanaian government put a halt to the training of male midwifes. About eighty of them had already graduated and started their work. What are their experiences with (male) midwifery in their country?
We asked Brilliant Gador (32), who is the administrator of the male midwives group in Ghana (West Africa). He is a midwife and medical sonographer and works at Ghana Health Services as a basic specialist trainee in Obstetrics & Gynaecology. Gador was initially trained as a public health nurse, in which capacity he was involved in introducing outreach antenatal care to the northern part of the Volta Region. His passion to reduce maternal and newborn mortality inspired him to become a nurse-midwife. In fact, he was part of the first batch of male midwives trained and licensed by the Nursing and Midwifery Council of Ghana (N&MC). Gador currently works at the Keta Municipal Hospital in the Volta Region, where he is involved in both managing and delivering midwifery care.
Midwifery training in Ghana
A straight degree in midwifery in Ghana takes four years of training and one year of internships. If you are already a nurse and want to become a nurse-midwife, it takes three additional years and one year of internship (to obtain a university degree) or two years study with one year of internship (to obtain a college diploma). In order to be allowed to practise, a midwife needs a license administered by the N&MC.
In September 2013, the training of male midwives started as a pilot project in three Ghanaian midwifery training colleges. Soon after, another college was added which offered midwifery training to nurses who had worked for at least 3 to 5 years and got a recommendation of their Ghana Health Services district director. In the beginning of 2017 however, the Ghanaian ministry of Health decided to stop the project. This, Gador adds ironically, was don “for reasons best known to our politicians and stakeholders”. A few of the male midwives are still in training, while about 70 of them are still doing their internship. About ninety male midwives are already practising. It is not yet clear what will happen to them now that the project has been cancelled.
According to media reports, the project was stopped after the muslim community in Northern Ghana voiced its objections against male midwives. It supposedly led women to stop attending health facilities at all and seek help from traditional birth attendants instead. While some pregnant women are uncomfortable with male midwives, others in the North are fine with them. As one of the women told Deutsche Welle, “I didn’t feel bad when a male midwife attended to me, since he was only doing his job”. People involved in the health care system emphasised the advantages of having male midwives. “It will be wise if we continue training them, because they can at least leave their families in town and work in the hinterland, where they can save mothers”, Esther Dodoo of Tamale Teaching Hospital told Deutsche Welle.
In Gador’s experience, patients generally respond “normal” when they find out their midwife is a man. In fact, he adds, “they often even seem to appreciate the presence of a male midwife more than that of a female midwife, and seem likely to ask for a male midwife again during their next delivery”. Gador on his part, sees no real difference between male and female midwives. “Every personality type has its advantages and disadvantages, those are not really gender specific.”
Gador performed a study on whether women would accept being attended to by a male midwife during delivery at what is now the Accra Regional Hospital and the Volta Regional Hospital in 2015 and 2016. “I used a sample of 200 pregnant women. 90% of them said that they would allow a male caregiver to attend to them, while 10% declined.” Those who had been attended to by a male midwife during delivery, said they would like a male midwife present during their next delivery as well.
Midwifery is generally a female dominated profession. Gador sees this as an advantage. “It allows you to acquire a lot of understanding of women, which is an added value when working with pregnant women.”
Added value of male midwives
In Gador’s experience, male midwives sometimes experience discrimination by other health care workers. “For instance in situations where all male midwives are sent to work in hospitals, while the female midwives are sent to health centres and areas that are hard to reach.” He feels it would be an advantage to have a male midwife around in those environments, which might be extra risky for women. “It is unfortunate that the director of the Ghana Health Service in Volta Region posted male midwives in central hospitals for work instead of sending them to rural areas.” It is in those areas where they are most needed, Gador adds. It led him to organise outreach missions to rural areas and to render mobile ultrasound services to the female midwives who are working there. In doing so, during the first six months of 2017 he referred forty women to hospitals for their delivery.
Gador feels that “while politicians and stakeholders go around the world preaching that maternal mortality in Ghana is going down”, there is still much to be done, “for instance in the field of preconception care for which there is no structured institution in the country at this moment”. Gador sees preconception care as a crucial tool in reducing maternal mortality. “It would be good for our people to know their health status before choosing to mother or father a child.” He is thinking about setting up preconceptional services. Against all odds, Gador relies on God and believes that his plans “will soon be materialized one after another, before my maker calls me”.
In 2015, the neonatal mortality rate in Ghana was 28/1000 live births,
the under 5 mortality rate was 62/1000 live births,
the estimated maternal mortality rate was 319/100.000 live births,
of the estimated 2800 maternal deaths 10 were AIDS related,
a skilled birth attendant was present at 68% of the births.
(Source World Bank, WHO)
It doesn’t mean things always go according plan. Despite being sponsored by Safe Motherhood, Gardor was denied a visum by the Canadian embassy in Ghana when he wanted to participate in the recent International Confederation of Midwives Conference in Toronto. This is a common challenge West-African males face when planning to travel abroad. They are suspected of leaving their countries without intending to return. Because of this, the male midwives of Ghana were deprived “of an opportunity to be represented on this global midwifery platform”, says Gardor. Ghana was not entirely absent, however, as the country was represented by ten of his female colleagues.
Use of Ultrasound Technology
Gabor considers the use of ultrasound technology lifesaving, especially during outreach missions. He uses the mobile sonoscape A6 and the Midray DP 2200 and DP 10. “Ultrasound technology allows us to select high-risk pregnancies and detect cases of placenta previa, malpresentation, Intrauterine Fetal Death (IUFD), ectopic pregnancies et cetera, and leads to timely referrals. Because of irregular cycles and women not monitoring their menstruation patterns regularly, the use of ultrasound technology is key to defining the term of pregnancy. Besides, we check for the number of fetuses, the presentation, the growth, the amniotic fluid volume, the placenta locations, the cervix dilatation, the heart rate and chambers of the heart and for any abnormalities.”
Normally, a first trimester scan is performed “to define the Estimated Due Date based on the Crown-Rump Length (CRL). The second scan is performed between the 16th and 28th week and the last one between the 36th and 40th week. Health insurance pays for these standard scans, but if the client needs additional scans, she needs to pay for them herself”.
Mobile Technology in Antenatal Care
When asked about the use of mobile technology in antenatal care, Gador reports on its huge potential and positive results. “In the North of Ghana, there is a public program in which every pregnant woman who attends antenatal care is linked up to a mobile phone database network. The networks updates her on scheduled appointments and allows her to contact her facility when she notices signs of complications during pregnancy.”
Gador, who is stationed in the southern part of the country, where such a program does not exist, has set up sort of his own network. He shares his mobile contact details and registers details of his his clients and their relatives. “This allows me to call them periodically when they are not regularly attending the clinic or when their estimated due date is due.”
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The MOTECH (Mobile Technology for Community Health) program
This is an initiative of the Grameen Foundation and the Ghana Health Services, consists of two applications for mobile phones. Through the Client Data App, local health care providers can see which women and infants under their care are scheduled (or too late) for a checkup, and can digitally report on care given to them. For clients, there’s the Mobile Midwife app, which provides expecting women and their families with weekly text or voice messages containing information they may need at that specific time of the pregnancy. This includes reminders of when to seek certain care, information on nutrition, fetal development and breast feeding, and tips on how to maintain a good health. At it’s launch in Ghana, the voice messages were delivered in English or one of several local languages, while the text messages relied on English only.
Good as this sounds, some critical remarks can be made. In a 2017 case study into the effectiveness of the MOTECH program, the researchers mention that evidence on the effectiveness of mHealth programs is still limited “and only modest gains have been observed for interventions aiming to improve provider diagnosis and management, and/or increased user demand through messaging using automated voice or SMS”.
With regard to the effectiveness of mHealth programs, it has to kept in mind that every technique has is limitations and may not entirely do what is was designed to do. In other words: not all MOTECH users received all the messages they were supposed to get. Besides, for a variety of reasons, not all messages that are delivered, are opened and listened to.
The researchers tried to establish the effectiveness of MOTECH by looking at the number of messages each woman listened to, compared to the number that they should have received. “Study findings suggest that exposure to messaging content declined from 25% in the 1st trimester to 6% at 6–12 months postpartum. This decline occurred as the number of eligible MOTECH users increased from 1,618 in the 1st trimester to 22,237 at 6–12 months postpartum. Across thematic areas, the mean proportion of women exposed varied from 19% for pregnancy care danger signs to 8% for infant care and development milestones.”
Midwifery Council of Ghana (N&MC, www.nmcgh.org)
Maxwell Suuk (2017), Ghanaian women reject male midwives. See: http://www.dw.com/en/ghanaian-women-reject-male-midwives/a-37733547
Ghana Health Services http://www.ghanahealthservice.org/
Ghana Ministry of Health (2014), Ghana Newborn Care Strategy 2014-2018. See: http://www.mamaye.org/sites/default/files/Ghana%20Newborn%20Strategy_2014.pdf
LeFevre, A.E. et al. (2017). Mobile Technology for Community Health in Ghana: what happens when technical functionality threatens the effectiveness of digital health programs? BMC Medical Informatics and Decision Making 17:27. See: https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-017-0421-9
World Bank, Neonatal Mortality Rate, Under 5 Mortality Rate, Maternal Mortality Rate. Estimates developed by the UN Interagency Group for Child Mortality Estimation (UNICEF, WHO, World Bank, UN DESA Population Division) at childmortality.org, and: Trends in Maternal Mortality: 1990 to 2015, WHO Geneva.
Maternal mortality in 1990-2015 WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division Maternal Mortality Estimation Inter-Agency Group GHANA
Photo 1-3, 6: Brilliant Gador
Photo 4: USAID U.S. Agency for International Development, Students Learn about Birth Process during Training. See: https://flic.kr/p/oH3tjj
Photo 5: The Maternal and Child Survival Program, GHANA - JHPIEGO. Mothers wait to see midwives and health workers to weigh and vaccinate their children up to age five in a clinic in Accra, Ghana. See: https://flic.kr/p/UHhXte