STRENGTHS AND LIMITATIONS OF THIS STUDY
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This study employed a descriptive exploratory (qualitative) design which allowed for a detailed exploration of pregnant and birthing women’s perceptions and attitudes towards male midwives, capturing the depth and dynamics of their experiences and views.
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This research addresses the perception and attitudes of women in the perinatal period in a culturally specific context, enhancing the relevance and applicability to similar African contexts and providing insights that can inform culturally sensitive midwifery practices.
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The adoption of Braun and Clarke’s reflexive thematic analysis allowed for the cognitive mapping of ideas which helped to enhance understanding, communication and reflexivity.
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The study was limited to two study settings in a rural area hence, the transferability of findings should be adequately contextualised.
Introduction
Globally, there has been increasing attention towards providing skilled health workers to reduce maternal and neonatal deaths. This aligns with the attainment of Sustainable Development Goal 3, target 3.1, which, among others, aims to reduce global maternal deaths to less than 70 per 100 000 live births by 2030.1–3 Like many other sub-Saharan African countries, Ghana is burdened with high maternal and neonatal deaths due to inadequate human resources, inequitable distribution of human resources and poor quality of care in the health sector. The number of maternal and neonatal deaths recorded in Ghana is about 308 per 100 000 and 22.8 per 1000 live births, with most of these occurring in rural settings while the WHO, through the Sustainable Development Goals, targets to reduce this to less than 70 per 100 000 live births by 2030.1 4–6
Ghana invests enormous financial resources into training midwives to help reduce maternal and newborn deaths.7 However, female healthcare workers mostly refuse to accept posting to healthcare facilities in rural communities in Ghana due to a lack of social amenities such as stable electricity, potable water, a good transport system and a reduced ability to initiate or maintain long-term relationships.5 8–10 This leads to fewer midwives working in rural communities as the majority of them are females, and this significantly undermines the government’s effort to reduce maternal and neonatal mortality and improve perinatal services.5 11
The training of males as midwives in selected healthcare institutions in Ghana started in 2013 as part of measures to address the severe shortage of midwives in the healthcare system and to address challenges related to posting female midwives to rural communities.8 12 Indeed, it is reported that males are more likely to accept postings to rural settings, as compared with females, especially when better economic conditions such as higher remuneration exist.10 The first batch of trainee male midwives were successfully recruited, trained and introduced into rural healthcare facilities in 2017. However, their services were met with negative attitudes from some communities for cultural and religious reasons, including the belief that a married woman should not expose her nakedness to another man other than her husband.12 13 In fact, some women in the perinatal period in some communities in the Northern, Upper East and Upper West regions of Ghana have avoided professional care in health facilities with male midwives against this backdrop1 7 According to a report from the Ghana Health Service, approximately 80% of women in the Northern region make use of antenatal care services (ANC), but only 37% opt for deliveries at health facilities. Likewise, in the Ashanti region, out of the 75% of pregnant women who attend ANC, 53% deliver in health institutions.7 Also, in the Kwabre-East District, Ashanti Region, health facilities with female midwives had more institutional deliveries and utilisation of ANC services than facilities with male midwives.14
Indeed, there have been similar reports of perinatal women avoiding care provided by male midwives in some communities in Nigeria, Zambia and Zimbabwe.15 16 While these reports and perceptions abound in Ghana, only one study has explored the acceptance and utilisation of male midwifery services from the perspective of women in the perinatal period but this was conducted in the northern part of the country.13 The identified reasons were culturally and religiously inclined and could be different in different geographical locations in the country.13
An exploratory study on the perceptions and attitudes of women in the perinatal period towards services provided by male midwives in southern Ghana was, therefore, considered necessary to add to the existing evidence-based data to inform policies and strategies needed to improve the uptake of maternal health services provided by male midwives. Given the urgent need to reduce maternal mortality globally and, particularly in Ghana, encouraging the acceptability and utilisation of perinatal services provided by male midwives in rural communities would make a significant contribution. Underlying the rationale for this study were the following important questions: (1) How do women in the perinatal period in southern Ghana perceive service provision by male midwives? (2) What attitudes do women in the perinatal period have towards service provision by male midwives? and (3) What are the challenges or motivating factors influencing the acceptance and utilisation of perinatal services provided by male midwives?
Definition of key concepts
Perception
Perception refers to the raw sensory data that women in the perinatal period use as input for decision-making and understanding of reproductive health services provided by male midwives.
Attitude
Attitude represents women in the perinatal period ’s predisposition to react or respond in a certain way towards male midwives based on their beliefs and emotions.
Methods
Study design and setting
An exploratory descriptive research design was adopted to provide comprehensive insights into participants’ perceptions and attitudes towards male midwifery services.17 The study was conducted at two public health facilities in the Kwabre-East District. The two health facilities house the largest midwifery centres with expanded ANC services in the district. The maternity units of the two selected public health facilities are the only units in the district with male midwives.
Research participants and sampling
The study participants comprised pregnant and birthing women within the reproductive age group of 15–49 years who received ANC, labour and postnatal services at the two public health facilities described above. The criteria for inclusion in the study were the ability to speak and understand either Twi (a Ghanaian local language) or English, a gestational period between 28 and 42 weeks, or postnatal women (within 72 hours), and experience with male midwifery services. Women who had refused care from male midwives were also included in order to explore their perceptions and challenges. Other important factors included being a resident in the Kwabre-East District for, at least, 6 months and voluntary consent. The exclusion criterion was perinatal women who declined to participate in the study. A purposive sampling technique was used to select pregnant women from the two healthcare facilities because they were the only facilities within the district with male midwives. Ten participants were recruited from the ANC and postpartum wards from both healthcare facilities. The selection process of the study participants was based on guidelines by Malterud et al.18 Participants were consecutively and purposively recruited and interviewed until the research team came to an agreement that concepts had been adequately explored, by which time 20 participants had been interviewed.
Data collection
The researchers developed a semistructured interview guide (online supplemental file 1) based on the literature review and research questions. The guide was pretested with two women in the perinatal period from a Polyclinic. Their transcripts were vetted by the last author, which led to the refinement of the guide. The study topic and purpose were explained to each potential participant, and a follow-up face-to-face interview was arranged for all those who consented to participate in a private, comfortable, conducive space (usually the consulting room or participants’ home). Each interview session lasted for 45–60 min and was conducted in Twi or English by the first and second authors who are fluent in both languages. Since the study was carried out at two study sites, DSB conducted interviews at one study site while VMKA did the interviews at the second study site. A maximum of three interviews was conducted per visit. DSB and VMKA met after each visit, compared field notes and transcribed the data verbatim. Data collection and analysis were done simultaneously. The process was audiorecorded with the consent of participants. The interview was initiated with the statement: ‘Please share your thoughts and feelings with me: what do you think about male midwives attending to women during pregnancy, labour or delivery’? Probing questions such as: ‘have you ever used the services of a male midwife?’; ‘If yes, what was your experience like?’; ‘What made you feel that way?’ were also used. The interviewers also used prompts such as ‘kindly elaborate further’ and ‘how do you mean?’ to assist participants in providing an in-depth description of their perceptions and attitudes and how that influenced their acceptance of male midwifery services. The audiorecordings and field notes were kept in secured drawers under lock and key and only accessible to the research team to ensure the protection and confidentiality of information. Data collection lasted for 1 month (from July to August 2020). Data saturation was achieved after interviewing 20 participants from the two health facilities with no new information emerging.
Supplemental material
Data analysis
The data collected were subjected to a rigorous thematic analytical process guided by Braun and Clarke’s19 20 recommendations. The lead researchers (DSB and VMKA) read the transcripts repeatedly. A coding framework was developed, incorporating key concepts, phrases and ideas that emerged from participants’ responses. The coding framework was refined through consensus among the research team, ensuring it captured the richness and diversity of the data. This framework organised and categorised the data according to relevant themes and subthemes. The identified themes were examined for patterns and sequences to uncover connections and relationships among participants’ perceptions and attitudes towards male midwives and their services. The major themes were synthesised to draw meaningful conclusions about the perceptions and attitudes of women in the perinatal period in the rural district of Ghana towards services provided by male midwives. This analytical process allowed for a thorough exploration and interpretation of the participants’ perceptions and attitudes, contributing to a deeper understanding of this important topic. The researchers returned the final organised data set to a sample of the participants for further insights and to provide an opportunity for them to reflect on any possible contradictions and differing perspectives (member reflection) but no further modification or data was generated from this exercise.21
Rigour and reflexivity
Since the research team was cross-disciplinary, there were several discussions that incorporated the diverse perspectives of both the practitioners and the social scientists to make conceptual and thematic interpretations. The research team discussed and adjusted the interview guide to strengthen the narrative approach through peer debriefing. The team also reflected on the analytical process throughout the study as a group to arrive at a consensus. The researchers ensured trustworthiness by engaging in detailed transcription and description of methods, systematic planning and coding following Guba and Lincoln22 guidelines. Moreover, this manuscript was guided by the Consolidated Criteria for Reporting Qualitative Research checklist23 (see online supplemental file 2).
Supplemental material
Patient and public involvement
None.
Findings
Characteristics of participants
The average age of participants was 28.15 years. Ten participants were Christians while the other 10 were Muslims. Only four participants had tertiary education, and three had no formal education. Seventeen participants were married while the remaining three were cohabiting. Five were expecting their first child (gravida 1). For most of them, it was the first time a male midwife was attending to them.
Main findings
The findings comprise views and experiences of the women in the perinatal period recruited for the study. Their perceptions, attitudes and challenges or factors affecting their acceptance of male midwives were the constructed categories from the data gathered. The experiences described in the interviews were organised into three themes: perceptions of women in the perinatal period towards service provision by male midwives, attitude of women in the perinatal period towards service provision by male midwives and multiplicity of challenges as shown in table 1.
Themes and subthemes
Perceptions on service provision by male midwives
Perceptions refer to participants’ views and understanding of service provision by male midwives during labour and delivery. There were varied perceptions among the participants. While some perceived male midwives attending to women in the perinatal period during pregnancy and labour as professionally safe and effective, others perceived it as socially unacceptable and potentially sexually violating.
Positive perceptions
Patient, supportive, caring and compassionate service
Some of the participants who had positive perceptions of male midwives considered them to be patient, supportive and caring during labour. This positive perception was mostly influenced by their previous positive experiences with male doctors vis-a-vis some negative experiences with female midwives who were considered abusive and impatient during delivery.
… I have been fortunate to be attended to by a male Doctor once. Frankly, although the experience was quite uncomfortable, I must say he was very caring and patient. He pampered and helped me endure the pain smoothly by massaging my back. I think male midwives will also be that good, patient and caring… (Participant 11, 31-35 years of age).
Skilled professionals
According to some participants, their observation of male midwives’ activities on the ward showed that they are indeed well trained and skilled in conducting labour and delivery. Apart from this, some perceived male midwives as smart and would act swiftly without undue delays, especially during emergencies.
…I think the male midwives are very good and skilled…… I have seen a male midwife assist a colleague pregnant woman to recover from blood loss…. when she delivered, she experienced blood loss and the female midwives tried but couldn’t stop the bleeding. A male midwife came to her rescue and helped her recover… (Participant 7, 18-24 years of age).
Negative perceptions
Feelings of sexual violation
Even though vaginal examination (done to assess cervical dilation and fetal head descent) is a standard medical procedure during labour, some participants considered it as a sexual act or being sexually violated when performed by a male midwife. Those who felt uneasy being attended to by a male midwife expressed dissatisfaction with possible vaginal fingering during the examination.
I feel it is unsuitable for a male midwife to insert his finger in our private part……I don’t know how to explain it, but I guess you understand. Don’t get me wrong, but it’s as if he (male midwife) is fingering you. (Participant 9, 31-35 years of age).
Almost all the participants expressed how uneasy their naked encounters with male midwives were or would be. Their perceived discomfort with male midwives was understandable because, in the past, hospital, ANC, labour monitoring and delivery were done mainly by female midwives. Male midwives were introduced into the facilities only in 2018.
Ok! I think the experience will be very uncomfortable because I would have to go naked before another man. I’m sure many women will have similar sentiments. (Participant 8, 31-35years)
Shyness
Some of the participants also expressed shyness about exposing their shapeless naked bodies (due to the pregnancy) to the opposite sex (male midwives) whom they do not have any intimate relationship with.
A participant said:
There will always be reactions of shyness and shame with the male midwife, especially because I have to expose my naked and shapeless pregnant body. I will not feel shy with a female midwife because she has the same sex characteristics as me (Participant 3, 31-35 years of age).
Attitudes towards service provision by male midwives
Positive attitudes
Women in the perinatal period’s attitude towards service provision by male midwives were generally positive, attributing it to their empathetic behaviour, reception, privacy and confidentiality of information.
Empathetic behaviour
Most of the participants who had experienced the services of male midwives found them to be more empathetic with their labour pain and stress. This is probably because of the popular notion that labour is painful and that male midwives could only imagine the magnitude of the pain felt by these women in the perinatal period. They reiterated that female midwives fall short of this virtue because they (female midwives) base childbirth on their own experiences.
A participant shared her observations as follows:
This is my first experience with a male midwife, and I must say he was very empathetic with my pain. He said sorry throughout. A female midwife would have told you I have also been in this situation before, and I did it (Participant 15, 31-35 years of age).
Reception of male midwives
The attitude of the women in the perinatal period towards the positive reception provided by male midwives was also positive, as most of them said the male midwives were welcoming and respectful and had time to explain the medical procedures and the labour process to their understanding.
A participant her satisfaction as follows:
…Yea! The male midwives are welcoming and respectful. During my first pregnancy, which resulted in a miscarriage, one attended to me, and how he spoke made me feel at home and relaxed. Even though I lost the baby, I wasn’t so much worried. He was good… (Participant 18, 31-35 years of age).
Privacy and confidentiality of information
Regarding privacy and confidentiality of information, almost all the participants expressed satisfaction. Most participants said the male midwives usually attended to them in a closed and confined environment with 2–3 female midwives. Participants also believed male midwives were good at maintaining professionalism and confidentiality, unlike some female counterparts who would leak their vital personal information and medical conditions through gossip.
A postnatal woman expressed her satisfaction as follows:
I think the male midwives will be good at keeping secrets because they do not usually gossip like the females. I believe the happenings here will not go beyond the walls of this maternity ward. (Participant 5, 25-30 years of age)
Negative attitudes
The data analysis showed that participants’ negative attitudes towards perinatal service provision by male midwives stem from their misconceptions about changing female gender domination and fear of being perceived as promiscuous.
Lack of awareness of the changing female gender domination of nursing and midwifery
The majority of the participants did not appreciate the changing dynamics of nursing and midwifery practice in Ghana where more males are being encouraged to join to address the inequitable distribution of healthcare professionals in the country. The male midwife is a trained health professional with the expertise to care for women during pregnancy, labour and delivery, yet participants were more likely to consider their gender first, before their professional training. Indeed, midwifery has been perceived, traditionally, as a profession for women, not men. This made it more difficult for them to come to terms with the fact that a male can be trained as a midwife.
Midwifery is a woman’s job. Yes! Women are the ones to care for their fellow pregnant women. It never said ‘midhusband’. (Participant 17, 36-40 years of age)
Fear
For some of the women in the perinatal period, the fear of community members or partners perceiving male midwives professional interactions with them as promiscuity or adultery motivated their negative attitude towards the services of male midwives. Culturally, the exposure of a married woman’s body to the opposite sex connotes promiscuity and could lead to divorce. This is evidenced in the following response.
…You see, the problem is, you have to undress before this male midwife; he looks at you, cleans your vulva and then checks how far you have dilated. This means he must put his fingers in your vagina high up, which is so intimate…… What if my husband or household members suddenly find us (me and the male midwife) in this position…? (Participant 12, 25-30 years of age)
Misconception
The perception that men have never been pregnant and lacked birth experience made it difficult for some participants to accept male midwives. They believe that male midwives cannot understand and interpret how women feel during labour. This influenced their initial negative attitude towards male midwives because of the stereotypical notion that only women could be good midwives. This was captured in a participant’s response as follows.
…I used to think that men can never work effectively as midwives because they don’t know what it means to be pregnant or give birth. (Participant 15, 31-35 years)
Multiplicity of challenges
Apart from the negative perceptions and attitudes of some women in the perinatal period, which became a major factor in their acceptance and uptake of the services of male midwives, participants were challenged by their cultural beliefs about the marriage system, norms, taboos, religion and unequal power relationship.
Breaching cultural and religious norms
Experiences and views of the women in the perinatal period reveal that male midwives’ roles as health professionals often intersect with a breach of cultural norms which is seen as a challenge influencing the acceptance and uptake of male midwives’ professional services. These were largely influenced by religious beliefs and cultural expectations of marriage.
Religious beliefs
Some participants identified religious beliefs as barriers to accepting and using male midwifery services. They explained that their religious faith, especially Islamic beliefs, forbids a married woman to expose her nakedness to any man other than their husband.
I am a Muslim and married to an Imam. My religion (Islam) forbids a man whom I’m not married to see my nakedness. If my husband hears of it, it could result in divorce (Participant 4, 31-35 years of age).
Cultural expectations of marriage
Although male midwives’ interactions with women in the perinatal period may be strictly professional, the concept of nudity and vaginal examination is often perceived to have sexual connotations and is culturally unacceptable.
Where I come from, our customs do not allow a different man to see a woman’s nakedness. It is not allowed. Our tradition forbids it……Yes, it is a serious offence in my culture and equates adultery or promiscuity (Participant 10, 25-30 years of age).
Some participants explained that marriage is deemed sacred and women, under the authority of their husbands, are forbidden by their customs and religion to go naked before another man or allow another man to touch certain parts of their bodies such as the neck, breasts, thighs, buttocks, lips and vagina. Per their culture, only husbands have permissive access to their bodies;
I’m a married woman. If a different man sees you naked or touches sensitive parts of your body, it means you have committed adultery against your husband. I am always disturbed. (Participant 1, 25-30 years of age).
Gender relation/unequal power relation
Per the experiences described and captured in this research, it appeared the male figure communicated authority and leadership. For some participants, their cultural and religious inclinations made them practically submit as passive recipients of the needed care. This was compounded by their lack of knowledge of the physiology of pregnancy and labour and the feeling that healthcare providers (even male midwives) were experts. Some participants, therefore, remained passive during care and hardly asked questions.
Umm, you know he (male midwife) is a man, and I’m a woman, so I just had to be calm and cooperate. Besides, he is a professional (expert) and knows what he is doing. (Participant 19, 36-40 years of age)
Summary of findings
The study elicited two contrasting perspectives—male midwives’ service affirmation and male midwives’ service disapproval. These were directly influenced by participants’ perspectives, attitudes and multiple challenges resulting from the interplay of culture and religion. These paradigms are shown in figure 1.
Perception and attitude of expectant mothers towards male midwives and its implication on their overall affirmation or disapproval of male midwifery services. ANC, antenatal care.
Discussion
This study explored the perceptions and attitudes of women in the perinatal period towards the services of male midwives. Participants’ perceptions of male midwives varied. While some perceived men attending to women during pregnancy and labour as ‘positive’, others perceived male midwives’ maternity services as ‘negative’. This study’s finding confirms those of previous studies in Uganda24 and Tanzania.25 Participants’ positive perception of services rendered by male midwives was based on the awareness that they are supportive and treat perinatal women with care and compassion. This was motivated mainly by their previous positive experience with male doctors and negative experiences with some female midwives. The finding is also similar to those of Alio et al,26 Kaye et al,24 Chilumba27 and Nyaloti28 that women in the perinatal period preferred male midwives as they were perceived as more caring, gentle and patient than their female counterparts. However, this contradicts the findings by Bwalya et al29 where female midwives were perceived as more caring and patient. Another reason for the positive perception towards male midwives was that they perceived male midwives as well-trained professionals based on their observation of male midwives at work. This also confirms similar findings reported by Nachinab et al,13 Chilumba27 and Nyaloti.28 In the view of Nyaloti,28 professionalism and quality of care should be the focus regarding male midwives’ services.
The negative perceptions were attributed to vaginal examination for cervical dilation and fetal head descent by the male midwife being considered as an intimate, potentially sexual, act. In the Nyaloti28 study, participants found procedures such as vaginal examination and urethral catheterisation as intimate. Some participants in the current study expressed how uncomfortable their ‘naked encounters’ with male midwives were. Others expressed mixed reactions of shyness and shame due to the exposure of their perceived shapeless naked body to the opposite sex with whom they have no intimate relationship. The above sentiments were echoed in studies by Nachinab et al,13 Yargawa and Leonardi-Bee,30 Chilumba27 and Nyaloti,28 where some of their participants felt uncomfortable, shy and embarrassed to be cared for by male midwives. Yargawa and Leonardi-Bee30 further revealed how shyness and perceived shame influenced some women in the perinatal period’s lack of preference for and poor patronage of services rendered by male midwives. The above finding is also in consonance with Martin et al31 and Bwalya et al,29 who reported that participants expressed discomfort and wished not to have been attended to by a male midwife. In this current study, participants’ perceived discomfort with male midwives was understandable because ANC, labour monitoring and delivery at these study sites were previously undertaken mainly by female midwives. Male midwives were introduced into the facilities recently and this remains a new experience to many.13
The attitude of some of the women in the perinatal period was generally positive. Positive attitudes resulted from the male midwives’ empathetic and receptive nature. Male midwives’ empathetic behaviour has been cited as a contributor to improving maternal and child health after delivery.25 This positive attitude is counterintuitive to findings by Shavai and Chinamasa,15 whose participants perceived female midwives as more empathetic.
Another important attribute of male midwives that influenced women in the perinatal period’s positive attitude was that participants felt male midwives maintained a very high professional code of ethics regarding confidentiality and would not leak information shared with them. The women’s views and experience of male midwives in this regard may be correct. A similar study has demonstrated that male healthcare providers have more knowledge of and positive attitudes towards patient confidentiality than females.32 These findings could be a positive reinforcement for more intake of males in midwifery training by the Ghana Health Service.7
Some participants’ negative attitudes resulted from their lack of awareness of the changing gender dynamics in nursing and midwifery because of the historical female predominance in both professions.33 This finding is also identical to findings in a study in Zimbabwe, which revealed that males were only trained as midwives based on the law because midwifery had historically been perceived as a female-dominated profession.15 Similarly, about 90% of women in Turkey felt midwifery is a female’s job.34 This lack of awareness essentially influenced participants’ negative attitudes towards male midwives.
The belief that men can never be good midwives because they lack experience with pregnancy and childbirth and possibly cannot understand how a woman feels during labour contributed to women in the perinatal period’s initial negative attitudes towards male midwives. This corroborates findings reported in the previous studies.25 35 36
More so, participants’ fear of being perceived as promiscuous for exposing their nakedness to and receiving care from an unfamiliar male figure influenced their negative attitudes towards male midwives. This confirms similar scientific evidence26–28 34 whereby exposure of participants’ nakedness to a male figure was equated to adultery. Fueled by the community’s ideals and perception, this fear ultimately has implications for women in the perinatal period’s acceptance and utilisation of male midwifery services. The community education and sensitisation of the existence and acceptance of professional male midwifery services may go a long way to correct the misconceptions. This may also have practical implications for midwifery deployment.
Participants had multiple challenges which inadvertently affected their acceptance and utilisation of male midwifery services. Challenges faced by women in the perinatal period with male midwives’ involvement in their care emanated from some cultural expectations about marriage and religious beliefs which prohibited a married woman from exposing her nakedness to a man she is not married to. The concept of nudity and vaginal examination was often perceived to have sexual connotations and was, culturally, unacceptable. Similar sentiments were expressed in studies by Nyaloti,28 Chilumba27 and Duman.34 Muslim women in the perinatal period, in particular, were hesitant to receive care from male midwives. Their heightened dislike for the services of male midwives is mirrored in the study by Allison37 in Equatorial Guinea, where women would rather bleed to death per vaginum than have a male midwife intervene. These factors may be considered major barriers to the acceptance and utilisation of maternal health services provided by male midwives. Married participants were primarily concerned about procedures requiring male midwives to touch their private and sensitive body parts, such as the breasts, neck, buttocks and vagina.
Similarly, in many Ghanaian cultures and religions, marriage is considered a sacred institution and only husbands have unbridled access to their wives’ bodies. Roberts33 and Fife38 expressed doubts about the distinct motive of men when they employ touch as a diagnostic procedure. Roberts33 also believes male midwives are intruders of other men’s ‘territory’. The education of men (particularly husbands) and their involvement in the antenatal and labour of their partners may be a promising approach to ease the tension and guilt experienced by these women in the perinatal period.
From the participants’ experiences, it appeared that the male figure communicated authority and leadership, as is the norm in many African cultures and religions.39 Influenced by their religious and cultural values, women in the perinatal period felt they literally had to passively submit to the male midwives to receive the needed care. This unequal power relationship further reinforces poor health provider–patient interaction. The Ghana Health Service and male midwives need to be aware of the effect of this unequal power relationship and devise acceptable interventions that will encourage women in the perinatal period to freely express their opinions, complaints, satisfaction and actively participate in their care. For instance, having female superiors for newly assigned male midwives would encourage women in the perinatal period to have a sense that their concerns will be handled by someone ‘like them’. This arrangement would give ample time for women in the perinatal period to develop familiarity with receiving care from male midwives.
Limitations of the study
The study was qualitative and limited to only two health facilities in one District in Ghana. The cultural and religious values and norms of the participants from these unique indigenous people may not be generalisable to other settings with different cultures. The study was also possibly limited by social desirability bias and lack of extensive data triangulation. We relied solely on the subjective experiences of women in the perinatal period whose responses may have been influenced by societal norms, values and beliefs.
Conclusion and recommendations
The factors contributing to women in the perinatal period’s negative attitudes and perceptions towards male midwives and subsequent uptake and utilisation of maternal health services were mainly unrelated to male midwives’ professional conduct. It was mainly a product of cultural and gender-sensitive factors rather than male professional midwifery competencies. Challenging the stereotypes by raising awareness about male midwives’ training, qualifications and the idea that midwifery is a profession open to all genders is crucial to improving acceptance and utilisation. Furthermore, in collaboration with relevant stakeholders, the Ghana Health Service needs to acknowledge and address cultural factors contributing to resistance towards male midwives in these communities. Deploying male midwives to communities where women are more open towards receiving their services will be a practical way to commence awareness creation of the presence of male midwives in the country. The incongruity between the perspectives shared by participants of this study only reinforces the concept of choice for clients receiving healthcare in the country. While there is the need to address the inequitable distribution of midwives in rural areas, hence the need to train and deploy male midwives, deliberate efforts should be sustained to ensure that the preference of some women in the perinatal period for female midwives is met at all times. Engaging male and female midwives who are couples (ie, married) to work in the rural settings would address the issues of personal relationships and perhaps greater acceptance in the wider community.
Data availability statement
Data are available on reasonable request. Not applicable.
Ethics statements
Patient consent for publication
Ethics approval
An ethical clearance was obtained from the Ghana Health Service Ethics Review Board (GHS-ERC002/02/19). Approval was obtained from the management of the two health facilities and the respective units’ in-charge. A visit to the health facilities and subsequent selection of women in the perinatal period also received approval from the District Health Directorate. Women in the perinatal period were duly informed of the research aims to ensure easy understanding and smooth data collection processes. Both verbal and written informed consent were obtained from the participants. Participants were assured of anonymity and confidentiality by explaining that no personal identifier would be used in the data or transcript. Instead, numbers were assigned and used on the transcripts and in the report to prevent data from being linked to them. All data were also kept under lock and key and on password-protected devices to avoid unauthorised access to them. Participation in this study was purely voluntary.
Acknowledgments
We would like to acknowledge the management and staff of the two health facilities for permitting us to carry out this research. We are also grateful to the participants whose consent and contribution have made this research successful.
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