Approximately 810 women died in 2017 from preventable causes related to pregnancy and childbirth [1]. Therefore, skilled care before, during and after childbirth is needed to help save the lives of women and newborns. Maternal and child health is a major priority in healthcare service delivery worldwide [2]. Women in both developed and developing countries use herbal medicine before pregnancy and during pregnancy and delivery, which has several consequences [3]. The use of herbal medicine has a long history, tracing its roots back to ancient and biblical days when there was no Orthodox medicine. Currently, both developed and developing countries use herbal medicine due to the presence of many traditional medicine practitioners [4].
Many cultures worldwide use herbal medicine to induce or accelerate labour, and the incidence of labour induction to shorten the duration of labour is on the rise. Most herbal medicine users are pregnant women who have no formal education, who have a low level of income and who mostly stay far from health facilities [5]. The majority of pregnant women use herbal medicine through the oral route and have confidence in its efficacy, safety and effectiveness [6]. Herbal medicine is used by women for maternal health-related issues, such as to induce abortion and labour, to correct infertility, for the treatment of pregnancy-related issues, for breast milk secretion and for general wellbeing during pregnancy [5].
Women who use herbal medicine during pregnancy and/or labour usually have a high risk of postpartum complications [7]. The use of herbal uterotonics can lead to hyperstimulation of the uterus, foetal asphyxia and several other adverse effects of labour [8]. Moreover, traditional medicine used by pregnant women is associated with several complications, including a ruptured uterus, a fresh still birth, a macerated still birth, a caesarean section and even death [9]. These herbal medicines have both uterotonic and nonuterotonic effects on labour and delivery and are mostly used to induce or augment labour in prolonged labour or postdate or to relax or widen the pelvis for delivery [8].
Maternal and neonatal deaths are still major challenges for most developing countries, with obstetric complications, especially postpartum haemorrhage (P.P.H.) being the major cause of maternal mortality [10]. The delivery of healthcare services is still poor quality in developing nations [11]. Maternal and foetal mortality and morbidity have remained high due to inadequate health services and inadequate emergency obstetric treatment. Childbirth is accompanied by numerous customs that are subject to ethnological research and are often rooted in traditional medicine or religion. Cultural influences and sociodemographic characteristics play an important role in a woman’s decision to seek maternal and child health services.
The induction of labour is the process of artificially starting labour by stimulating the uterus with oxytocin or manually through the rupture of amniotic membranes; this process is usually not risk free, and most women find it to be uncomfortable [12]. The induction of labour is an obstetric procedure recommended when the benefits to the baby and mother outweigh the benefits of continuing the pregnancy; this procedure usually involves complications and failures and must be performed under close monitoring, proper selection of clients and good preparation [13].
Labour induction also changes the normal physiological processes that accompany childbirth and increases the risk of adverse pregnancy outcomes such as postpartum haemorrhage, neonatal mortality, foetal distress, uterine rapture and premature birth [14]. Oxytocin is a natural hormone produced by the hypothalamus and is responsible for the activation of sensory nerves during labour and breastfeeding [15]. Clinically, commercially manufactured synthetic oxytocin is administered to commence or increase uterine activity to reduce the duration of labour [16].
The induction of labour is not free from risk and must be performed with caution because the procedure involves hyperstimulation of the uterus and foetal distress. Herbal medicine used by pregnant women has long-term effects on both mothers and babies [17]. Many pregnant women in the Tamale Metropolis use prepackaged herbal medicine before and during pregnancy [18]. Health-related factors such as cost, distance, access and unavailability of medications influence the utilization of herbal medicine by pregnant women [17].
All women should be given a prophylactic dose of oxytocin as soon as they give birth; if they start to hemorrhage, they should also be given a treatment dose of oxytocin, which is greater than the prophylactic dose [19]. There is also a traditional manufactured form of oxytocin (kaligutim) that pregnant women use to start labour. Kaligutim is the local name for the mixture of some special plant parts or a combination of plants prepared and given to pregnant women to start or accelerate the process of labour in the northern part of Ghana [17].
Ideally, women should take medical drugs during pregnancy (folic acid and fersolate) to help prevent birth defects and congenital malformations such as neural tube defects of the foetus and spinal bifida during pregnancy [20]. However, in recent decades, women worldwide have used herbal medications during pregnancy and labour, with some taking both herbal medicine and orthodox medicine at the same time [21]. However, little is known about the use and safety of these medicines, especially during pregnancy, and their dosages, indications and contraindications are not known [22].
There are studies on herbal medicine use by women during pregnancy and labour, but there is currently no literature on the use of Kaligutim (local oxytocin) for labour induction among pregnant women in Ghana, but similar studies have been conducted in Uganda, Malawi, Tanzania, and Nigeria. Despite the efforts of the government and other nongovernmental organizations to ensure maximum coverage of skilled delivery to help reduce maternal and neonatal mortalities, women still use locally prepared oxytocin to induce labour. Although herbal medicine is commonly used by pregnant women, healthcare providers, especially midwives, are often unprepared to communicate effectively with patients or make proper decisions concerning complementary and alternative medicine use, especially during pregnancy and labour [23].
It is well known that herbs have played a vital role since the precolonial era during pregnancy, delivery and postpartum care in many parts of the country, but there are still few data on the use of herbs among pregnant women in Ghana [24]. Towards the end of pregnancy, many women are tired and eager to welcome their babies into the world. Moreover, as the expected date of delivery approaches, these women are given local oxytocin by their mothers’ in-laws, grandmothers, mothers, or TBAs or even by the women themselves to start labour at home before going to the health facility [25].
Medicinal plants that are used to hasten or speed up labour are mostly taken towards the end of pregnancy or the beginning of labour [26]. Even after delivery, these herbs may be found in small amounts in the mother's breast, and some may cross the placental barrier and have harmful effects on the baby. The use of herbal medication by pregnant women is inevitable given that up to 80% of people who live in developing nations rely on traditional medicine for their healthcare needs [18].
The situation in Ghana, especially Northern Ghana, is not different, as pregnant women continue to use herbs despite the availability of health facilities [24]. The use of herbal medicine (kaligutim) among the Ghanaian population is alarming. Pregnant women in Tamale use herbal products at a rate of 42.5% prior to pregnancy and 52.7% during pregnancy [27]. Residents of Tamales who seek healthcare services in hospitals or herbal clinics are therefore at a greater risk of experiencing adverse consequences from drug-herb interactions [28].
Herbal product manufacturers should clearly state that pregnancy is a contraindication, and vendors should use caution when selling these items to pregnant women [27]. The use of Kaligutim (local oxytocin) by pregnant women is a maternal and child health problem. Herbal medicine used by pregnant women has long-term effects on both mothers and babies [17]. Unfortunately, maternal and neonatal deaths may occur, and hence, there is a need to examine midwives’ perspectives on local oxytocin use during labour, its effects on the progress and outcome of labour, and the relationship between kaligutim use and birth outcomes among pregnant women in the three major government hospitals in Tamale Metropolis.
Theoretical foundation
This study adopted and adapted Andersen’s (1968) behavioural model of healthcare service utilization (use and nonuse of health services). Aersen’s healthcare utilization model is a conceptual model aimed at demonstrating the factors that lead to the use/nonuse of health services. This study was guided by Andersen’s behavioural model of health service use as a theoretical framework to identify the effects of Kaligutim on the progress and outcome of labour and to establish the relationship between the use of Kaligutim and nonuse of kaligutim and birth outcomes. The behavioural model is a multilevel model that incorporates both individual and contextual determinants of health service use.
Conceptual framework
Many people rely on products made from medicinal plants to maintain their health or treat illness, and current general development trends in developing and developed countries suggest that the consumption of medicinal plants is unlikely to decline in the short to medium term because of the benefits to consumers, producers, and society as a whole [29]. Therefore, there is a need to increase our understanding of what motivates the consumption of medicinal plants, despite the barriers to the establishment of solid evidence on the safety and efficacy of herbal medicines and related products [29].
This unified conceptual framework offers a step towards establishing a comprehensive approach to understanding the experiences midwives encounter when their clients use herbal medicine to induce their labour. The exposure variable in this study refers to kaligutim (local oxytocin) used by pregnant women in the three major government hospitals to induce labour through several routes, including oral, rectal, and vaginal routes, among others. When oxytocin is used by pregnant women, it can produce several results that can be immediate or late.
The results elicited on labour are termed the outcome variables, which can be immediate outcomes (the progress of labour) or outcomes after delivery (the outcome of labour). The progression of labour includes three stages: progressive dilatation of the cervix from 1 cm to 10 cm, delivery of the baby and expulsion of the placenta. Several factors can be used to determine the progress of labour (obstructed labour, prolonged labour, nature of uterine contractions, precipitated labour, foetal distress, and poor progress of labour).
The outcome of labour on the hand refers to what happens during the delivery of the baby, how the baby was delivered, foetal conditions and maternal conditions. The following factors were used for the purpose of this study to determine the outcome of labour (mode of delivery, postpartum haemorrhage, ruptured uterus, cervical tear, birth asphyxia, uterine atony, maternal mortality, and neonatal mortality). This study focused on the immediate effects of Kaligutim (on labour progress) and the effects of Kaligutim after delivery (on labour outcomes) and the relationship between the use of Kaligutim and birth outcomes.