Bouncing her four-month-old daughter on her knee, Perpetual Guore recalled the stark difference between this pregnancy and her last one. When pregnant with her son, she wanted to go to the health center for prenatal care but, “my mother-in-law and husband said no,” she said. “It’s laziness. I don’t want to work”
“My husband doesn’t want me to die and leave him… He now knows the importance of helping a woman when she’s pregnant.”
When she went into labor, elderly women came to her home to assist with the birth, bringing with them herbal preparations. And when she began bleeding and became unconscious, “they were now pouring their libation, calling their gods,” she said. But they didn’t take her to a hospital.
During her next pregnancy, however, Guore’s family not only encouraged her to seek skilled health care, they relieved her of her heavy chores. “My husband doesn’t want me to die and leave him,” she said. “He now knows the importance of helping a woman when she’s pregnant.”
Guore’s family learned about healthy practices in pregnancy, childbirth, and newborn care through Community Benefits Health, our pioneering pilot in the Upper West region of Ghana, where poverty and maternal and newborn death rates are among the highest in the nation.
Health messaging plus incentive
The program, in the districts of Lambussie, Wa West, and Jirapa, promotes healthy behaviors by combining educational messaging with the promise of a non-financial incentive that benefits the whole community if certain conditions are met.
While everyone stands to gain from the incentive — such as a water pump or a community-run ambulance known as an emergency transport system — the incentives are particularly beneficial to pregnant women and new mothers. An emergency vehicle gets an expectant woman to a health center quickly, while a closer borehole solves the problem of mothers traveling long distances daily to collect water.
Concern and our implementing partner, ProNet North, turned on the new water pumps and delivered the ambulances to twelve communities in March. As clear water gushed for the first time, community members clapped, sang, and danced in celebration, while passing around a wooden bowl from which to sip. The festivities marked not just a closer water source but also the fact that the communities had achieved successes aimed at improving the survival and health of their mothers and babies.
But the heart of this behavior change program is its robust messaging spread through radio programming, meetings or durbars, and outreach by health workers and community members trained as peer educators. Especially popular are the dramas and videos created and performed by community members. Everyone comes out to see the homegrown movies, a festive nighttime activity after a long, hard day of working on the farm.
“If a chief gets up and says that no woman should deliver in the house, the people will take it seriously,”
Among the practices Community Benefits Health aims to make common are four prenatal care visits beginning as soon as the woman knows she’s pregnant, skilled delivery, and a post-delivery check for moms and babies. It encourages women to start breastfeeding as soon as their baby is born and to continue breastfeeding exclusively for six months.
Addressing cultural barriers
But cultural traditions are hard to break. In these communities, disclosing a pregnancy within the first few months is considered bad luck, the nutritious first breast milk (colostrum) is considered “dirty” and thrown out, pregnant women visit a traditional healer instead of a health worker, and women often deliver at home without skilled care.
As the influential people in a woman’s life may want her to continue these practices, Community Benefits Health targets them as well with education on healthy pregnancies, childbirth, and on caring for their babies.
“This time the communities designed the program, and that’s why they have fully embraced this.”
“If a chief gets up and says that no woman should deliver in the house, the people will take it seriously,” said community health officer Desmond Tampuori. “That is why we involve the community leaders like the chiefs, the traditional rulers, the mothers-in-law and husbands. The woman herself cannot make the decision to go to the hospital or to seek medical care. It is the leadership in the house — the husband, father-in-law, the mother-in-law — they make the decisions. That is why we involve them.”
“My child will grow up”
Community members say they’re seeing a difference. Tampuori says men now routinely accompany their pregnant wives to his clinic whereas in the past the husband’s presence was considered “funny.”
“My child will grow up, go to school, and become somebody in the future.”
What’s more, he added, “men are now involving themselves in things that were meant for women, like fetching water or cooking. In our traditional set-up, it was not allowed for a man to cook for the family.”
Bayor Basilite said he took up house chores to support his wife during her pregnancy and after childbirth. “My colleagues were always making fun of me because they have been saying that fetching water, cleaning, and the house chores are activities for the woman,” Basilite says. “When I fetch water, some of them will be insulting me but I don’t care.”
He said that his hope for his daughter’s future drove him. “Before this project, children were dying and the mothers were dying from birth,” Basilite said. “My child will grow up, go to school, and become somebody in the future.”
A tale of two pregnancies
The first time Zumatiere Yiryo became pregnant, she continued to do all her usual chores, sowing the seeds on the farm and drawing and carrying water. Yiryo never visited a health center, believing instead that the herb preparation the traditional healer gave her each week to drink would ensure a smooth delivery and a healthy baby. “I delivered in the house. [It was] just me and my mother-in-law. I was sick and I was helpless. I was bleeding a lot and in pain,” Yiryo recalled in a soft voice. “He was born with rashes on his body and he died on the tenth day.”
Later, Yiryo watched dramatic videos that her neighbors performed in. “I realized that I was part of that family that went to the witch doctor and lost the baby, because it happened to me,” she said. “I decided to go the health facility.”
“We’ve already lost a baby and it was not easy for us… we are hoping that this time we can have a child and be happy together.”
Now, five months pregnant, she says she goes to the clinic regularly. Her mother-in-law fetches the water and her husband cooks.
“We’ve already lost a baby and it was not easy for us,” said her husband Zumayanga Yibile. “So we are hoping that this time we can have a child and be happy together.”
Engaging the communities
From the outset, the communities were involved in the design of the Community Benefits Health program. They decided what type of incentives to offer. They also formed governing committees composed of respected community members who created constitutions and targets for receiving the incentives, such as men accompanying their wives to the clinic and attending meetings about health issues related to pregnancies, deliveries, newborns, and children.
Engaging the community throughout was key to the program’s success, said Wahid Yahaya, project manager at ProNet North.
“In NGO work, we’ve always designed programs for the communities,” Yahaya said, referring to non-governmental organizations. “But this time the communities designed the program, and that’s why they have fully embraced this.”