Stories From Ghana: When Cultural Norms and Life-Saving Care Come Together

Photo: The Bill & Melinda Gates Foundation. This blog was originally published in Impatient Optimists. Written by Ane Adondiwo, Isaac Amenga-Etego, Ireneous Dasoberi, Ernest Kanyoke. 

To mark the critical first 28 days of a newborn’s life–the neonatal period (when a baby is most at risk)– in the lead up to the Global Newborn Health Conference, Gary Darmstadt and others will be sharing, via Twitter, 28 days of “Did You Know?” facts about newborn health. Follow @gdarmsta, share the facts widely using #Newborn2013 and we can work towards saving newborn lives together.  

Did you know that in many traditional cultures around the world, newborns are not allowed outdoors or around outsiders for weeks for fear of “evil spirits” and “evil people” doing them harm just by looking at them in a certain way or cursing them? Where do these beliefs come from? There are likely different reasons for these beliefs, depending upon the region, but in communities in which so many babies don’t survive the first month of life, people develop their own explanations for why bad things happen and what they must do to protect themselves and their families. To protect the health and lives of both women and babies, we must find ways to work with communities who hold these beliefs to provide care that we know will save lives.

For example, concern about the “evil eye” at birth, in some communities, makes it quite difficult for women to have a skilled attendant during delivery or to get early postnatal care, both of which can improve the health of mom and baby. How can this cultural norm be accommodated while promoting life-saving interventions?

Project Fives Alive
is trying to answer that question in northern Ghana. This project is a collaboration of the Institute for Healthcare Improvement, the National Catholic Health Service and the Ghana Health Service to accelerate the achievement of Millennium Development Goal Four to reduce child mortality in Ghana.

Communities and the health providers who serve them are working together to develop innovative approaches to adapt these cultural norms and change how mothers care for their newborns.

Here are a few examples from our work with promising results:

Babies born outside the community of the Boyelle community in Upper West Region of Ghana are considered “unclean” until elders perform special rituals to “cleanse” the child to accept them back into the community.  The midwife in the sub-district, Jane Kuudamnuru, convinced them to do the same ritual for children born in a health facility. Because of this change, 100 percent of women from Boyelle community delivered in a health facility between December 2008 and October 2009, a drastic change from zero for most of 2008 before this new idea was introduced.

Midwife Theresa Kpinbo, in Douri (also in Upper West Region) converted one of the small rooms in her clinic exclusively for postnatal care so women would be assured that their babies would be attended to in private, away from the curious and potential “evil eyes” of other women. Now women come for postnatal care in the first week of life with their babies hidden under a shroud until they are alone with a health staff in the special room. Postnatal care visits went from zero to 88 percent within the first 48 hours after delivery and up to 80 percent for a follow-up care visit on day six or seven.

In Busunu, midwife Martina Naagmentoma decided to ask the families in the community if she could attend the naming ceremony for their babies, usually held seven days after delivery. They were happy to invite her as she was not a member of the indigenous community and thus was less likely to be one of the “ill-wishers.” Furthermore, being a health worker, she was held in high esteem by the community.

So Martina uses the naming ceremony as an opportunity to check-up on mothers and their newborns on the seventh day and provide health education messages about exclusive breastfeeding, hygienic care of the umbilical cord, and keeping the baby warm.

As of February 2013, an astounding 95 percent of women were provided a first postnatal care visit – and 90 percent, a second visit. Just as amazing – there were no newborn deaths recorded in the facility or the community during 2012.

And in Zorko, in Upper East Region, the midwife Janet Adongo and her team convinced families to let them enter their compounds through the back gate to provide postnatal care within the first week. This resolved the concern that visitors or strangers who use the front entrance during the first week after birth would bring the “evil eye” with them. Since these and other changes, the percentage of newborns provided postnatal care within 48 hours of birth increased from 32 percent to 100 percent, while those who received a follow up visit by the seventh day of birth increased from 1 percent to 87 percent.

Project Fives Alive!
describes these ideas and many others in a detailed how-to guideline, called a “change package.” It has been promoted throughout northern Ghana for the past three years with modifications to suit different local contexts and, as we’ve noted, is clearly generating evidence of impact.

We know that different regions hold different cultural norms, but what’s ultimately important is improving the health of mothers and babies. We learn a lot from listening to communities and working with them to develop solutions that are both culturally-appropriate and clinically-safe.

Our goal is to adapt cultural norms to safer health practices and spread these types of practices across similar contexts in the country of Ghana, so more children are alive at five.

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