A Qualitative Study on Women’s Experiences of Intrapartum Nursing Care at Tamale Teaching Hospital (TTH), Ghana

Abstract

Introduction: Labor and delivery process is an exciting, anxiety-provoking, but rewarding time for a woman and her family after successful delivery of a newborn. The intrapartum period is the time where mothers expect more care. Taking care of a mother through delivery with no side effects is the task of a professional midwife who is trained with the skill to take the responsibility of caring for mothers and babies. Therefore, the aim of this study was to explore mother’s experiences regarding quality of intrapartum nursing/midwifery care.

Methods: Focused ethnographic study was employed. Data were collected from May to June 2016 TTH, Ghana using semi structured interview guide. Purposive sampling was employed to recruit 20 participants. Eight individual interviews were conducted in the post natal ward after 48 hours of delivery, followed by three focus group discussions two weeks after delivery when mothers visited post natal clinic. Interviews lasted for about 30-45 minutes during each session. Data were analyzed using thematic analysis.

Results: The average age of women were 29 years with ranging from 19-43 years. Participants’ experiences of nursing/midwifery care during birth were influenced by reception and respect, provision of information, technical skill, providers’ behavior, pain management and availability of nurses/midwives.

Conclusion: The study findings have revealed that women’s experience of care is affected by a wide range of determinants. Therefore, maternal health programs and policies in Ghana must take into account women’s perspective on the care they need and their feedback on services they receive. Nursing education should re-enforce communication/relational skills.

Introduction

Despite efforts made in reducing maternal mortality worldwide, the pace of progress has been slow in most developing countries which led to unmet maternal health target of Millennium Development Goal (MDG).¹

Developing countries account for approximately 99% (302000) of the global maternal deaths in 2015, with sub-Saharan Africa alone accounting for roughly 66% (201 000) of maternal deaths.¹ It is estimated that one-half to two-thirds of maternal deaths occur within 24 hours of labor and delivery. It is outlined that staff quantity, quality (skills) and attitudes are possible contributory causes to maternal deaths in resource poor countries.^2,3

Labor and delivery process is an exciting, anxiety-provoking, but rewarding time for the woman and her family.^4,5 This is the time where mothers expect more care from nurses and midwives. Taking care of a mother through a successful delivery with no complication is the task of a professional midwife.

She is trained with the skill to take the responsibility of caring for mothers and babies. The quality of midwifery care is one of the issues, which has major effects on the results of delivery.⁶ Labor and delivery units in most hospitals in Africa, especially Ghana functions through the nurse-managed model.

The nurse-managed labor model is used to describe a labor and delivery nursing practice in which nurses/midwives have an autonomous role where he or she is required to make clinical decisions involving patient care with little contribution from the obstetricians.^7,8 As a result, nurses/midwives have a greater ability to have an influence on the women’s childbirth experience and birth outcomes.^8-10 The birth of a child is often described as one of the most important and memorable experiences in a woman’s life. For many mothers, the birth experience has long lasting effects despite its relative transience.

Positive experiences are an important beginning of the bonding process between mothers and newborns, improving the new family’s adjustment during the postpartum period.¹¹

Patient satisfaction has received a great deal of attention in health care systems and is an important indicator of quality of care. Patient satisfaction is a significant health care outcome in today’s health care system and is one of the most frequently reported outcome measures for quality of care and provision of health care services.^12,13 Intra-partum satisfaction is a broad multifaceted concept which involves mothers’ experience of labor, birth and immediate postpartum.^12,14 In determining maternal satisfaction level, studies have confirmed that the nurse during the period of delivery would be the deciding factor whether the woman would have a positive or negative experience during this period of childbirth.¹⁵

Recent studies in Africa revealed that the overall maternal satisfaction with delivery services rendered at most hospitals were of a high percentage. Ethiopian studies showed 80.7% and 81.7% satisfaction level of delivery services.^16,17 However, the level of satisfaction of mothers in some African countries is not enough; only 51.9% and 56% of mothers were satisfied with delivery services in South Africa and Kenya, respectively.^13,18 Where as in Ghana a recent study conducted in Southern part revealed that 62% of postnatal mothers were satisfied with delivery care.¹⁹

Most studies in Africa have shown that women seeking maternity services are most likely to have bad experiences during labor and delivery. These bad past experiences can have negative influences on mothers seeking maternity services in the same facility or other facilities. For example D’Ambruoso et al., demonstrate that in Accra, Ghana, women in labor and delivery, experienced poor interactions with health care providers and described them as impatient and unkind.²⁰ Also in Tanzanian, majority of the women reported that they had been neglected, sometimes resulting in fatal consequences.²¹

Physical abuse appears to be a worryingly common experience for many women during intrapartum period.²² In a South African Human Rights Watch report; physical and verbal abuse by maternal health care providers were reported by more than half of the women interviewed. At least 30 women reported that nurses pinched, slapped, and handled them roughly during labor.²³ A recent statement by the World Health Organization (WHO) and the Human Reproduction Programme calls for greater attention, research and advocacy around the maltreatment of women at the time of childbirth in facilities.²⁴

Though most previous studies have revealed that mothers have been maltreated during labor and delivery, no study have been conducted on mother’s experiences about intrapartum nursing care in the northern part of Ghana. This study therefore, explore mothers’ experiences regarding quality of intrapartum nursing/midwifery care offered at the Tamale Teaching Hospital (T.T.H) Ghana.

Materials and methods

Focused ethnographic research methods²⁵ were employed to generate data. Ethnography research method was preferred because it generates rich and detailed accounts of clinicians’ professional and inter-professional relationships, their interactions with patients,

and their approaches to delivering care, as well as in-depth accounts of patients’ care experiences.²⁶ Ethnographic research method was used in this study because of the cultural relation of participants in the northern part of the Ghana. Unlike traditional ethnography, focused ethnography defines a specific topic for study, and focuses on a small portion of a society rather than the whole society. Researchers are often natives to the study setting, and their familiarity with the culture allows for use of a compressed timeframe for fieldwork.²⁵

A purposive sampling procedure was used to recruit a maximum of 20 participants. Participants were mothers of 19 to 43 years of age and had received intrapartum care from TTH were recruited. Eight mothers participated in individual interviews after 48 hours of delivery and 12 women participated in three focus groups (FG), composed of groups of three (3) after two weeks of delivery when mothers were visiting the postnatal clinic (PNC). In accordance with the qualitative descriptive approach, the principle of saturation (whereby no new information emerges with the addition of new cases)²⁷ was used to determine the sample size of 20. The inclusion criteria were mothers who attended delivery services in the study hospital and would be willing to participate in the study with no major/minor complications, mothers who had spontaneous vaginal delivery after 48 hours and were discharged. Exclusion criteria were mothers who were mentally or critically ill, had birth complications, had caesarean section, forceps deliveries, vacuum extractions, and who were not up to 48 hours after delivery.

Purposive sampling was employed to recruit participants based on the inclusion and exclusion criteria. Eight individual interviews were conducted with volunteering participants after 48 hours of delivery. This was followed by three focus group discussions two weeks after delivery when mothers were visiting post natal clinic. Each focus group consisted of four participants. After spontaneous vaginal delivery, mothers were sent to the postnatal ward. The eight individual interviews were conducted at the postnatal ward in an enclose room where participants felt free to answer questions. Face-to-face in-depth interviews were conducted. Open-ended questions, asking the mothers to tell their birth stories and their perception/experience about nurses’ attitude and behavior about care they received. Also prompt questions were used when needed.

During the individual and each FG interviews, there was a moderator and an assistant moderator. The moderator led the discussion, kept the conversation flowing while the assistant moderator operated the tape recorder, took comprehensive notes, and responded to unexpected interruptions and kept track of time. The interviews lasted on the average 30-45 minutes. All participants were interviewed once. Recordings were translated and transcribed verbatim in English.

The data were analyzed using thematic analysis. Statistical Package for Social sciences (SPSS) version 22 was used for data entry and descriptive analysis of the participants’ demographic data. Qualitative analysis focused on participants’ perception/experiences of care they received during intrapartum period; what they liked about the care they received and what the problems or constraints were. After each interview, data collected in audio tape were labeled and transcribed followed by translation from Dagbani to English (for data that was in Dagbani). The transcriber and translator was someone who spoke English and Dagbani well. Transcript was proofread twice for accuracy of what was really provided by participants. The organized data was transferred into a computer in the way that all information with the same idea was put together for easy retrieval. Attention was given to ensure accuracy and avoid losing any valuable information during the process. Data was sorted and coded manually, through that the researcher noted the occurrence of key patterns of statements. Sub categories were formed from identified codes of which later categories were generated and finally a theme was developed representing the whole idea of narrative data. Trustworthiness of the data was reinforced by meeting the criteria for transferability, dependability, conformability, and credibility.^28,29 A native of the northern part of Ghana, conversant in the local dialect (Dagbani) and English reviewed a randomly-chosen translated transcript for accuracy in translation. Transcripts, data coding, categorization and themes were regularly cross-checked to correct errors of fact or errors of interpretation and also questioning by research members. Data was never altered by any research member during cross-checking.

Detailed field notes and reflective notes were kept and reviewed frequently for emerging ideas. Data triangulation³⁰ was employed by gathering multiple perspectives on women’s experiences and by carrying out observations. Permission was sought from management of the manager Hospital to use the facility and ethical approval obtained board for the study. Professionally, researchers were obliged to protect participants from harm and also respect their rights. All research assistants were trained on ethics and participant’s rights as well as the methods to ensure confidentiality. At the ward level permission was granted from Nurse Managers and ward in-charges to access the participants. The purpose of the research was explained to the potential participants and their participation sought. Researchers also informed participants about their right to withdraw from the study at any point in time without any consequences.

Those who were willing to participate signed a written informed consent and for those who could not read and write formally also thumb printed. Participants were also assured of confidentiality and anonymity of the information obtained during investigation.

Results

Majority 16 (80%) of the respondents were in 25-34 years. The average age of women was 29 years with ages ranging from 19years to 43years. On religious distribution, majority 80% of participants were Muslims and 20% Christians. The non-educated persons constituted 25% of the total population of the study. The majority of persons (35%) have completed primary school. With secondary school leavers, they represented 20% of participants. Participants that had tertiary education at various levels represented 20% of the study population. On employment bases, majority of participants representing 45% were not employed, 10% were students, 25% were not formally employed and 20% were formally employed in various organizations. All participants representing 100% had spontaneous vaginal delivery. Majority of the participants (45%) chose to deliver at TTH because of quality care by health professionals (Nurses and Doctors), 25% of respondents chose the hospital for convenience sake, 15% of respondents chose the hospital because of the availability of modern facilities and the remaining 15% were referred from other facilities. With regards to duration of stay in the ward, 40% of respondents stayed within 48 hours after delivery, majority of women were discharged after 48 hour of delivery.

Table 1. Socio-demographics characteristics of the study population.

Variable	N (%)
Age
15-24	1 (5)
25-34	16 (80)
35-54	3 (15)
Religion
Muslim	16 (80)
Christian	4 (20)
Education
No education	5 (25)
Primary education	7 (35)
Secondary education	4 (20)
Tertiary education	4 (20)
Occupation
No occupation	9 (45)
Student	2 (10)
Informal	5 (25)
Formal	4 (20)
Obstetric characteristics
Reasons for choosing this facility
Modern facilities	3 (15)
Quality care	9 (45)
Referral	3 (15)
Convenient	5 (25)
Duration of labor
48hours and above	12 (60)
24-48hours	8 (40)

Women experiences about reception and respect

Participants spoke about the ‘warm and friendly’ attitude of nurses/midwives. In terms of satisfaction with their experience, it was important that they were treated in a pleasant manner. Almost all participants reported that they were well received in labor ward by nurses/midwives. The reasons given were; they received them with a smile, they were not shouted at, neither spoken to harshly, or with bad temper. The women felt they were spoken to with calmness, were respected and quickly assisted and delivered them when they came distressed in labor.

A participant narrated: “when I arrived the midwife smiled at me and gave me a warm welcome. She was very friendly and jovial. They were as well supportive and they took good care of me throughout my delivery process, indeed they are God sent people.” (Participants 1, FG 3)

Another mother added: “when I arrived, I am well. One of the midwives helped me to my bed; she made me comfortable on bed and reassured me of good nursing care …....” (Participant 8, individual interview)

Women experiences about the technical skill of nurses/midwives

Majority of the participants described nurses/midwives to be knowledgeable and skillful in providing nursing care during labor and delivery. A participant, who was referred from a district hospital while in labor, stated that nursing care was adequate because she was examined frequently, nurses were always available, and willing to assist when the need be. She further reported that care at the hospital was much better because nurses/midwives collaborated with doctors to care for her; especially the infusion was always flowing at any particular time.

Participant 2 individual interview, describes the nurses’ skill “at the district facility the health personnel always have problem in searching for my veins, when I arrived at this facility...and immediately she inserted the needle and it went straight into my vein, the next thing I saw was drugs being mixed and pushed through my vein and water hanged for me”

Also (Participant 1, FG2) described personal as being knowledgeable and skilled in discharging their duties “…during my delivery process, the young midwife said my baby’s head was big, so she was to incise my private part to enable easy passage of my baby and immediately she did that and with little push I saw my baby come out. She worked with tact and skill which I admired a lot”.

Women experiences about provision of information

Participants reported that they were given explanations on various procedures and assessments.

Participants also raised a point that, they and their families were always involved in decision making concerning their care.

Another participant narrated that “the nurses/midwives always tell me that my cervix has opened to this level (example four centimeters) and others after assessment…. interestingly she interpreted my laboratory results for me, truly I thought she was a medical doctor because she explained herself very well to my understanding.” (Participant 2, FG2)

Women experiences about confidentiality and privacy

A minority of the participants reported on confidentiality in provision of care. Participants described confidentiality as health workers keeping secrets about delivery issues. Most participants expressed poor provision of privacy in the delivery room. They expressed that the delivery room had no partitions to provide privacy. Majority of mothers expressed satisfaction with privacy provided at the labor ward, because there were enough screens to provide privacy during examination or when undergoing a procedure. Participants mentioned that nurses/midwives spoke to them quietly and properly to maintain privacy.

Participant 4, FG 2, explained how confidentiality was maintained regarding her experience during labor and delivery. “During my delivery a lot of things happened. It got to a time I messed myself up. The midwives just helped me as if I was their daughter. If she was someone else she would be saying I am the one who delivered her and I messed myself up. With this I see that, the midwives kept confidentiality. She did not say anything to anyone”

“As for me I was not impressed about the way the delivery room was, it had no partitions or screens. You will be wailing or crying because of pain whiles seeing your colleague woman also in the same situation. Though we were all women but at times some needed privacy.” (Participant 1, FG1)

Women experiences about providers’ behaviors

Despite the fact that some participants had good experiences, there were others who experience otherwise. Although there was high level of satisfaction with services, the behavior of health care workers was one of the most significant concerns raised by the women. Some few mothers said staff were unfriendly (shouting, ignoring, harsh, and impolite) and the majority described staff as friendly, knowledgeable and skilled. All participants said they would like to come back to the facility to deliver because they had good care compared to other delivery centers they attended. Despite few respondents complains about the attitude of some nurses/midwives, they still felt intrapartum nursing care was good.

A participant narrated: “one of the nurses shouted at me not considering I could be her mother’s age mate. I was not happy. In my labored pain, I tried communicating with her but she ignored me but a colleague of her near-by came and had time for me, she had the touch of my daughter and she was wearing a smiling face…………… I was annoyed and unhappy but the others saw me through my delivery process successfully without any complication. They actually kept a smile on my face.” (Participant 2, FG 2)

Most mothers accepted disrespect or poor attitude of some nurses/midwives in order to obtain the care needed at that particular time. Therefore, they sought to avoid conflict with nurses by not expressing their feelings:

Another respondent said “the midwives were angry with me and showing disrespect by shouting and talking any how to me when I was in labor pains. I wasn’t cooperating with them, whatever they tell me to do I will do it passively or will not just do it at all. The labor pains were too much to bear. Though they showed disrespect I just had to cope with them in order for them to deliver me successfully.” (participant 2, FG 1)

Some participants thought otherwise, most of them said nurses were friendly;

One of the participants narrated: “I delivered my second child in this hospital and the care was very good. I'm sure my colleague women here will testify to what am saying [most women agreed with her]. I arrived seriously in labor pains; I was met with a happy smile and a warm welcome. Ah! The midwives were courteous and caring. I tell you I'll never forget the good experiences from nurses. I vowed that my subsequent deliveries will all be at this hospital." (Participant 1, FG 3) All the women in this focus group seconded to her claims and also shared similar good experiences with nurses/midwives.

Women experiences about pain management

Pain management is an integral part of labor care. If pain is well managed mothers are most likely to have good perception and experience about the care they receive from nurses/midwives. Some participants mentioned that they did not get tablet to take for pain neither injections but they got encouragement and reassurance from the staff during labor. Mothers said they did not really feel the labor pains as they thought it could be because the nurses/midwives kept on assuring and encouraging them.

One woman narrated: “when I was in pain the midwife kept reassuring me. In fact, she pampered me till I delivered my baby.” (Participant 7, individual interview)

Participant 3, group 3 expressed that; “though I did not take tablets and injections for pain but still my pain was a little reduced by nurses/midwives because they made me feel the pain was part of labor and delivery. They always encouraged me to sit up, lie down or play music on my phone”.

Women experiences with midwifery care during normal delivery

An optimal birth is the golden standard for labor and delivery care. This optimal birth experience includes a birth that has a reduced risk of harm and intervention as well as full parental involvement and family support. And this had a positive birth perception and experience on mothers that had normal delivery process without complications. Women’s positive perception of the care is important as it influences whether the women’s will use or not use the services in the facility.

A participant narrated that; “the nursing/ midwifery care was good and I am thankful. If I was home it would not have ended well, the baby or myself would have died because things were becoming though but with the expertise knowledge and skill of the nurses/midwives my delivery was successful. I have been helped a lot by the nurses/midwives in this hospital. I am looking well and the baby is ok”. (Participant 3, FG 2)

Women experiences about availability of midwives/nurses

Mothers spoke about the importance of a member of staff always being with them, and this generally referred to the presence of a nurse/midwife. They narrated that, if a midwife is always present, their fear and anxiety was always alleviated. They had the assurance that competent professionals were with them. Participants observed that there was always adequate staff on every shift or duty schedule.

A participant narrated; “the presence of a midwife or nurse in the labor ward was always an assurance that they had concern about our welfare………they always examined and assessed as each and every time they deemed it necessary.” (Participant 4, FG1).

All participants felt that there was adequate number of staff present each and every shift. As one participant expressed that; “…in fact nurses/midwives were always present in the labor ward and the delivery room” mothers in this focus group nodded their heads in support of her statement.

Discussion

Pregnant women will deliver in health facilities if they are satisfied or have good experiences with the care that they receive. However, for women to be really satisfied they must be well informed and know what to expect. This will then provide a basis for possible enquiry. The findings of the study showed that mothers had good information about their care during delivery and knew what to expect next, mothers had good perception and experiences of intrapartum nursing care. However, the participants viewed being respected, good reception, interpersonal interaction, emotional support, encouragement, reassurance, availability of nurses/midwives at all times, as well as nurses providing skilled care as good quality nursing care.

Few of the participants during labor did not accept some behaviors of nurses/midwives but still were satisfied with care and planned of coming back to the facility for their next delivery. Some participants said they were being shouted at, by harsh and intolerant nurses/midwives. Possibly, the participants felt they should tolerate the nurses/midwives behavior in order to be assisted or cared for, or also felt that the facility had specialized professionals ranging from nurses/midwives to doctors. This is consistent with Yakong et al., findings where women accepted disrespect, intimidation and scolding they received in order to obtain care.³¹ Similarly, Delvaux et al., noticed that most women were satisfied with the care they received during and after labor despite low technical quality and unfavorable personal support given to women.³²

Information provision and emotional support from the staff during birth are clearly important to mothers. Mothers will always have fore knowledge of what to expect and the progression of her condition.

Studies on women’s care experience reported that, women who were not informed and not educated on labor pain and coping strategies were dissatisfied and expressed their wish to be well informed and take active role in their care.³³ Mothers were highly satisfied with the information they received during birth. They expressed that, nurses explained each and every procedure that was going to be carried on them and they knew what to expect next. Our study finding is in accordance with a study done in South East England, which revealed that parents were highly satisfied with the information that they received during birth.³⁴ Similarly, a study by Lumadi and Buch found that mothers were satisfied with information given them during labor by expressing that they had good communication and education given them about the care of their babies.¹⁸

Participants in this study acknowledged that nurses/midwives were very knowledgeable and skilled in providing care. Our findings agree with the study done in India, which found out that, women were more satisfied with maternal health services when they had good perception about the technical quality of care or the provider to be technically competent.³⁵ This finding is in contrast with a study by Kumbani et al., where mothers did not comment much on the technical skills of health workers. They further explained that participants might have not known what to expect.³⁶

Pain is a normal physiological process during labor; sadly, most nurses/midwives feel that women must endure the pain. A study in Benin found that midwives expected women to endure labor pains and complaints were treated with ridicule and humiliation.³⁷ Women in labor know that pain management is an important component of providing quality care to women in labor and makes labor less traumatic. Women always expect health professionals to know that labor comes with pain and should be well managed.

Goberna-Tricas et al., found that women thought the experience of pain was unnecessary and it was sensible to prevent the pain.³⁸ During labor nurses/midwives are always expected to provide non-pharmaceutical and pharmaceutical pain relief. However, most of the times, health workers’ convictions about labor may also affect their use of both non-pharmaceutical and pharmaceutical pain relief measures. In the current study some participants did receive pharmacological and non-pharmacological management³⁹ of pain during labor and delivery process, and were very satisfied with the way they were managed during that period.

Women will always prefer a nurse/midwife to be available when they are in labor and during delivery. Availability of doctors and nurses at all times, especially during emergencies, was considered a prerequisite to good care in India.³⁵ Non-availability of nursing personnel and inadequacy of staff to attend to women, especially during labor, was reported as a cause for dissatisfaction with services in Ghana and Nigeria.⁴⁰ Wild et al., found that when women were left alone they were reluctant to seek care in subsequent pregnancies.⁴¹ Gao et al., reported that women preferred to deliver at home because nobody looked after them in the hospital.⁴² In a study in Zambia one of the major complaints with services was being left alone in labor too long.⁴³ But participants in this study were satisfied with the availability nurses/midwives and never complained of absence of staff. The presence of nurses/midwives gave participants the assurance that they were in safe hands of professionals. The availability of nurses/midwives per every shift was because the ward had adequate number of nurses/midwives and there was punctuality per every shift.

Attitude of health professionals plays an integral part of women satisfaction/dissatisfaction with care during labor and delivery process. In the current study, nearly all mothers appreciated nurses/midwives attitude during labor and delivery. Participants reported that nurses/midwives were friendly, welcoming, respectful, sociable and very lovely to interact with. Their grievances were met because of the interactive nature of nurses/midwives in the labor ward. This study is parallel with a whole lot of studies carried out in Ghana, South Africa and Benin where mothers were not treated well by health providers during labor and delivery process. These women complained of impatient and unkind behavior, they were severe neglected, verbal and emotional abuse, treatment refusal and physical assault, such as delete and slaps on their faces and thighs.^20,37

Almost every mother in the study was highly satisfied with the care during labor and delivery services. Though two of the mothers had their personal view about the care they received, they were also satisfied with care but not highly satisfied. In general, all mothers were satisfied with the care they received and will also like to come back for their next delivery in the same facility. Most studies done across Africa on maternal satisfaction with overall delivery services (intrapartum nursing care) revealed high percentages (80.7%, 79.1%, 81.7%, 62%) of maternal satisfaction but not 100%.^16,17,19,44 We speculate that the differences could also be attributed to the study type and also the location. The current study was a qualitative study dealing with a few study participants’ whiles the rest of the studies were quantitative dealing with larger sample sizes.

Conclusion

Women’s perception of care is important as it contributes to women’s satisfaction with maternal services. Therefore, nursing/midwifery services provided during labor and delivery should be quality without any negative attitude during this period. Nurses/midwives should show empathy and provide care that is acceptable and suitable to all women based on set procedures.

The study findings have revealed that women’s experience of care is affected by a wide range of determinants. Therefore, maternal health programs and policies in Ghana must take into account women’s perspective of the care they need and their feedback on the services they receive. In nursing education there should be incorporation or re-enforcement of communication/relational skills of nurses/midwives. Further research should be focused towards interpersonal behaviors and communication skills of nurses/midwives.

Acknowledgments

The authors wish to extend their gratitude to the management of Tamale Teaching Hospital and all women that participated in this study.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.

Please cite this paper as: Afaya A, Yakong VN, Afaya RA, Salia SM, Adatara P, Kuug AK, Nyande FK. A qualitative study on women’s experiencesof intrapartum nursing care at tamale teaching hospital, Ghana. J Caring Sci 2017; 6(4): 303-14. doi:10.15171/jcs.2016.029.