Emergent and often interlinking themes were identified from the narratives obtained from midwives. Midwives' years of practice ranged from a minimum of three years to near retirement. Most of the participants were providing frontline care. Five themes emerged from the individual interview transcripts regarding the challenges experienced by midwives in delivery care to rural women;
- Inadequate infrastructure (lack of beds and physical space)
- Lack of logistics
- Shortage of midwifery personnel
- Lack of motivation
- Limited in-service training
Inadequate infrastructure (lack of beds and physical space)
One of the key themes that emerged from data analysis was inadequate infrastructure (lack of beds and physical space) to render quality care. All the participants acknowledged that inadequate infrastructure such as rooms to accommodate many labouring women was a challenging and frustrating. They further bemoaned that lack of beds syndrome affect quality of midwifery care because women that are layed on the bare floor is difficult to nurse patients. They further expressed that cases that they could handle in the facility were referred to district hospitals due to lack of beds and these actions carried out by the midwives brought inconviences to the pregnant women and their families which may have had negative repercussion on facility deliveries. The midwives also said that due to lack of beds they have to always bend or squat to deliver care to the women and this has a lot of negative health implications such as spinal and waist pains.
“In rural areas, we have a big problem with wards and beds. Sometimes, due to inadequate rooms and beds, anytime we have more than three women in labour, we are compelled to put them on mattresses on the floor because the room can only contain three women at a time”.
“In fact, I must say that working in a rural area is like a hell. …due to lack of space, we have to refer some of them to the district hospital which at the normal circumstance should not be the case”.
“…hmmm …..it’s a serious problem here (referring to a rural health facility). There are no enough beds and mattresses. Sometimes, when the expectant mothers are more than the number of beds, we put the mattresses on the floor”.
Lack of logistics
All the participants expressed their frustrations due to lack of equipment and basic consumables to work with. They recounted many occasions when they could not perform the full iterative midwifery care to expectant mothers due to lack of consumables and this affected quality of midwifery care. The midwives further explained that they always have to improvise with the little resources at their disposal in other to meet the health needs of the expectant women but knowing that it wasn’t the best practice. They had to improvise to safe the life of the mothers and the unborn babies. The midwives felt that they are being neglected by the healthcare managers because they make requisitions for these logusitics to be provided in order to improve quality midwifery care in the rural settings but their efforts and voices are not being heard. Below are some narrations by midwives;
“In this clinic, the challenge we face here is not only about beds and space to put the clients but also, consumables and supplies such as gloves, liquid soap, cotton and gauze to work. We have always been improvising in every procedure we perform in this clinic”.
“…as I talk to you now, we do not have disposable gloves and detergents to work now. How can you work without these basic things? Sometimes, I ask myself is it because we are working in the rural area that they (referring to health care managers) do not care about us?
Shortage of Midwifery personnel
The shortage of midwives in the distraict was a major issue across the facilities as midwives lamented about this chronic shortage which affects their ability to function effectively due to work over load. Most midwives were complelled to work for 24hours because there was no one to take over the shift for them to also have some rest. They explained that working for a whole week without rest may lead them into a stress state which will further affect their ability to deliver care care effectively.
“In this clinic, we are only three midwives manning the maternal and child health services. We currently handling the responsibilities of about five or more midwives which is making us get stressed up…”.
“…we are dying here because of work. We are only two midwives and the work is just too much for us”.
“I must say that we don’t rest at all. We work 24 hours and sometimes, seven days a week without rest”.
Most of the participants also indicated that apart from working around the clock, due to the shortages of midwives in the rural areas, many of them hardly take their annual leave as required by every worker in the public service. Some participants felt that they were exshauted due to continue care delivery without periods of breaks and this was causing burnout among them.
“We hardly take our annual leave because of the inadequate number of midwifery staff in our facilities. I have not taken my annual leave for three years I have been posted here as a midwife”.
“We are now getting tired and weaker because we have no time to rest, and we do not even take annual leaves like our colleagues in other parts of the country.”
Lack of motivation
All the participants in this study acknowledged that in spite of the workload on midwives working in rural areas of northern Ghana, they were not given any incentive such as rural incentive allowances to enable them to put up their best. The midwives felt on noticed and not recognised by the efforts they put in the delivery of quality maternal and child health services in the communities.
“I must say that it appears no one recognises our work in this remote area where there is a lot of workloads . I have never been paid any allowance since I started working in this remote area for almost five years now”.
Some of the participants indicated that although there are other health personnel such doctors who are given rural incentive allowances as a form of motivation for them to accept posting to rural and deprived areas of northern Ghana, midwives are not given any allowance.
“I feel we (midwives) are unfairly treated by the Ghana Health Service or government because we are rather working in the most deprived and rural areas of northern Ghana. Doctors do not work in these areas, and yet we are not given any rural incentive allowances. But, medical doctors who are rather not working in these areas are paid 10 per cent of their salary as rural incentive allowances as motivation for them to accept posting to northern Ghana”.
Participants believed that because there is no incentive given to midwives in rural areas in northern Ghana, most of their colleagues who were posted to the rural areas refused to report to their post.
“I must say that because the government does not give us any rural incentives or any form of motivation, some of our colleagues (midwives) who were posted here to work refused to report or assume duty. Some reported, but because there was no motivation given to us, they asked for a transfer to other regions”.
Most of the participants indicated that they were compelled to work at rural areas even though they were not given any rural allowances as a form of motivation because they did not have the opportunity to leave the place.
“….As for me, I am still working here because I did get the opportunity to leave here. If there were jobs in the towns and cities that can employ us, I would have left here a long time ago. But, there are no jobs, and our managers would not also agree for us to go on transfer”.
Almost all participants indicated that if the government wants midwives to accept posting to rural and deprived areas in the northern part of Ghana, there is the need to implement rural incentive allowances for midwives to encourage them to accept posting to rural areas to reduce maternal mortality.
“….If the government wants midwives to accept posting to these remote areas, then the government should introduce rural incentive allowances for midwives to encourage them to accept posting to rural areas like here (the study setting) like the government has done for medical doctors”.
Although most participants felt not motivated by management and the government, a few however, admitted that promotions and study leave with pay were granted much faster for midwives working in rural areas than those working in the developed towns and cities. Some midwives still expressed great concern that though the study processes are much faster, they are not able to still further their education due to staff shortage.
“…..But I must say that our only advantage and motivation for working in these rural areas is that our promotions are faster than our colleagues in the towns and cities.”
“One good thing for working in these rural areas is that we can be allowed to go to school for further studies with pay when we work for at least two to three years..but the disadvantage is that when you are the only one or two in the facility, it is always very difficult to leave the facility when there is no one to offer care for the labouring mothers.
Limited in-service training opportunities
All the participants acknowledged that there were limited in-service training opportunities for midwives working in rural communities to improve their knowledge and skills like their counterparts who are working in the towns and cities.
“It is a disadvantage of working in rural areas in the north. As we are working here, we are only able to attend few in-service training courses, unlike our colleagues who are in the cities who have the opportunity to attend lots of workshops training all the time”.
Participants pointed out that although they occasionally attend workshop training organised by Ghana Health Services and other institutions due to shortage of midwives in rural areas, many of them did not have the opportunity to attend those workshops.
“I must acknowledge that workshops have been organised by Ghana Health Service and other bodies, but due to our number (a few staff) we are unable to attend most of those workshops. I, for instance, had to miss three to four workshops because anytime there is a workshop and I planned to attend I will end up being alone in my health facility, and you cannot close down the facility and attend the workshop”.
Participants reported that apart from the fact that they are unable to attend many workshops organised by the Ghana Health Service and other organisation to improve their knowledge and skills, they also do not have the opportunity for effective mentorship and coaching by senior and experienced midwives in the rural areas.
“….Hmmm, our problems are just too many. When you are posted here, you are just on your own. There are no senior or more experienced midwives here to mentor or coach us…”
“As for this place, when you are posted here, you are your own boss. No senior midwife to teach you or mentor you. We are always on duty alone or with one person, so who will teach the other?”