Chikotsa--secrets, silence, and hiding: social risk and reproductive vulnerability in central Mozambique

Concealed pregnancy as an act of care? A qualitative analysis of motivations for concealing and non-disclosure of early pregnancy in The Gambia

BACKGROUND

A barrier to achieving first trimester antenatal care (ANC) attendance in many countries has been the widespread cultural practice of not discussing pregnancies in the early stages. Motivations for concealing pregnancy bear further study, as the interventions necessary to encourage early ANC attendance may be more complicated than targeting infrastructural barriers to ANC attendance such as transportation, time, and cost.

METHODS

Five focus groups with a total of 30 married, pregnant women were conducted to assess the feasibility of conducting a randomised controlled trial to evaluate the effectiveness of early initiation of physical activity and/or yoghurt consumption in reducing Gestational Diabetes Mellitus in pregnant women in The Gambia. Focus group transcripts were coded through a thematic analysis approach, assessing themes as they arose in relation to failure to attend early ANC.

RESULTS

Two reasons for the concealment of pregnancies in the first trimester or ahead of a pregnancy's obvious visibility to others were given by focus group participants. These were 'pregnancy outside of marriage' and 'evil spirits and miscarriage.' Concealment on both grounds was motivated through specific worries and fears. In the case of a pregnancy outside of marriage, this was worry over social stigma and shame. Evil spirits were widely considered to be a cause of early miscarriage, and as such, women may choose to conceal their pregnancies in the early stages as a form of protection.

CONCLUSION

Women's lived experiences of evil spirits have been under-explored in qualitative health research as they relate specifically to women's access to early antenatal care. Better understanding of how such sprits are experienced and why some women perceive themselves as vulnerable to related spiritual attacks may help healthcare workers or community health workers to identify in a timely manner the women most likely to fear such situations and spirits and subsequently conceal their pregnancies.

Professional competition amidst intractable maternal mortality: Midwifery in rural Pakistan during the COVID-19 pandemic

Low-income countries with intransigent maternal mortality rates often follow WHO guidelines that prioritize access to skilled, or professionalized, prenatal and birthing care. Yet the impact of these initiatives in areas still suffering high maternal mortality is opaque. Despite heavy and long investments, the professionalization of midwifery in Pakistan is incomplete, and declines in maternal mortality have plateaued. Traditional midwives have lost status, but they continue to see clients and have influence in their rural communities. We conducted a rapid ethnography among traditional midwives (Dais) and trained Lady Health Workers (LHWs) in two communities of Attock, Pakistan from May to July of 2020. Our findings underscore the importance of long-term presence and trust to maternal care, especially in conditions of resource scarcity or fear (e.g., fear of COVID). We provide evidence of overt disparagement of Dais by LHWs; (2) illustration of the conflicts between gender norms and biomedical priorities of hospitalized births; and (3) exacerbated fear of hospitals during COVID, which served to highlight the advantages of Dai care. Professionalization programs for midwifery must include structures and training to ensure collaborative communications across the country's midwives. Failure to respect the rational decisions of traditional midwives and their patients in circumstances of scarcity, high stress, and isolation only ignores the material and cultural conditions of these vulnerable communities.

Understanding the risk perception of visceral leishmaniasis exposure and the acceptability of sandfly protection measures among migrant workers in the lowlands of Northwest Ethiopia: a health belief model perspective

Background

Visceral leishmaniasis (VL) is the leading cause of health concerns among Ethiopian migrant workers. Understanding risk perception and health-protective behavior are significant challenges in the prevention and eradication of the disease. As a result, studies are required to assess these important epidemiological factors, which will provide guidance on how to assist migrant workers in taking preventive measures against VL.

Method

We conducted qualitative research among migrant workers on seasonal agricultural farms in Northwest Ethiopia between June and November 2019 to assess their perception of the risk of contracting VL and their willingness to use protective measures against the disease. Seventeen focus group discussions and 16 key informant interviews were conducted to study migrant workers’ risk perception in relation to sandfly bite exposure and use of sandfly control measures. For analysis, all interviews were recorded, transcribed, and translated. ATLASti was used to perform qualitative content analysis on the data.

Result

Migrant workers are fearful of VL because of previous exposure and the disease’s prevalence in the area. They believe, however, that VL is a minor illness that is easily treated. While Insecticide Treated Nets (ITNs) are widely accepted as a protective measure, there are still reservations about using them due to the seasonality of the transmission, difficulties in hanging them on farm areas, and a preference for alternative traditional practices. Regardless of perceived self-efficacy, the central cues were the message delivered by the health workers and an increase in sandfly bite irritation. Based on the findings, three levels of intervention modalities are suggested: 1) increasing pre-arrival awareness through outdoor media (posters, stickers, billboards), 2) encouraging proper use of protective measures upon arrival at farm camps, and 3) informing departing workers on disease recognition and best practices for health-seeking continuous use of protective measures at home.

Conclusion

This finding suggests that VL prevention interventions should focus on individuals’ perceptions in order to promote consistent use of protective measures. The findings are highly useful in planning effective interventions against VL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13406-3.

Bear bile use at the intersection of maternal health in Cambodia

BACKGROUND

The consumption of bear gallbladders and bear bile in Southeast Asia is a persistent threat to bear populations. As part of a larger effort to understand the characteristics of bear part consumption in Cambodia, we uncovered a consumer base of women seeking treatment for post-partum and uterine ailments.

METHODS

To better understand this aspect of consumption, we interviewed 122 women in seven different provinces in Cambodia, probing into the motivations and influences for using bear bile, as well as what types of ailments Cambodian women use it for.

RESULTS

We found that it is generally used by young or expecting mothers, and for such issues as post-partum "fatigue" (toas in Khmer), which could encompass post-partum depression. A desire to be supported by kin networks seems to facilitate the continued use of bear gallbladder and bile for these purposes.

CONCLUSIONS

We suggest that efforts to reduce consumption should focus on encouraging older kin to change their means of support to Western/biomedical and by extension non-wildlife alternatives.

Factors affecting early identification of pregnant women by community health workers in Morogoro, Tanzania

BACKGROUND

It is recommended that Antenatal Care (ANC) be initiated within the first trimester of pregnancy for essential interventions, such folic acid supplementation, to be effective. In Tanzania, only 24% of mothers attend their first ANC appointment during their first trimester. Studies have shown that women who have had contact with a health worker are more likely to attend their first antenatal care appointment earlier in pregnancy. Community health workers (CHWs) are in an opportune position to be this contact. This study explored CHW experiences with identifying women early in gestation to refer them to facility-based antenatal care services in Morogoro, Tanzania.

METHODS

This qualitative study employed 10 semi-structured focus group discussions, 5 with 34 CHWs and 5 with 34 recently delivered women in three districts in Morogoro, Tanzania. A thematic analytical approach was used to identify emerging themes among the CHW and RDW responses.

RESULTS

Study findings show CHWs play a major role in identifying pregnant women in their communities and linking them with health facilities. Lack of trust and other factors, however, affect early pregnancy identification by the CHWs. They utilize several methods to identify pregnant women, including: asking direct questions to households when collecting information on the national census, conducting frequent household visits and getting information about pregnant women from health facilities.

CONCLUSIONS

We present a framework for the interaction of factors that affect CHWs' ability to identify pregnant women early in gestation. Further studies need to be conducted investigating optimal workload for CHWs, as well as reasons pregnant women might conceal their pregnancies.

Cultural beliefs and practices of women influencing home births in rural Northern Ghana

Background: One of the maternal health care strategies identified by the World Health Organization as being crucial for saving lives of pregnant women, which also serves as an indicator for progress in reducing maternal mortality, is the provision and utilization of skilled birth care. Despite the importance of skilled birth care in preventing maternal morbidity and mortality, many women continue to give birth at home without the assistance of skilled birth attendants in rural communities of Ghana. Purpose: The purpose of this study was to explore the cultural beliefs that potentially influenced the choice of home births among rural women in Ghana. Methods: A qualitative approach was utilized to conduct this study. Twenty participants who delivered at home were purposefully selected and interviewed individually. Semistructured interviews were used to explore the cultural belief patterns that potentially influenced the choice of home births among women in rural Ghana. Thematic analysis approach was used to analyze the data. Results: Four major themes emerging from the data analysis which influenced rural women's decision to give birth at home are namely: opportunity to access psychological support through family members, opportunity to access culturally acceptable food, opportunity to adopt a birthing position of choice, and opportunity for safe and culturally accepted disposal of placenta. Conclusion: This study concluded that the cultural beliefs held by these women greatly affected their decision to deliver at home. Hence, there is a need for health care managers to facilitate collaborative practices between the skilled birth attendants and traditional birth attendants. This is because this approach could enhance the integration of the cultural beliefs and practices of women in the orthodox health care delivery system to facilitate the utilization of skilled birth care.

Gambian cultural beliefs, attitudes and discourse on reproductive health and mortality: Implications for data collection in surveys from the interviewer's perspective

Background

A community’s cultural beliefs, attitudes and discourse can affect their responses in surveys. Knowledge of these cultural factors and how to comply with them or adjust for them during data collection can improve data quality.

Objective

This study describes implications of features of Gambian culture related to women’s reproductive health, and mortality, when collecting data in surveys.

Methods

13 in-depth interviews of female interviewers and a focus group discussion among male interviewers were conducted in two rural health and demographic surveillance systems as well as three key informant interviews in three regions in The Gambia.

Results

From the fieldworker’s viewpoint, questions relating to reproduction were best asked by women as culturally pregnancies should be concealed, and menstruation is considered a sensitive topic. Gambians were reluctant to speak about decedents and the Fula did not like to be counted, potentially affecting estimation of mortality. Asking about siblings proved problematic among the Fula and Serahule communities. Proposals made to overcome these challenges were that culturally-appropriate metaphors and symbols should be used to discuss sensitive matters and to enumerating births/deaths singly instead of collecting summary totals, which had threatening connotations. This was as opposed to training interviewers to ask standardised and precise verbatim questions.

Contribution

This paper presents indigenous Gambian solutions by fieldworkers to culturally sensitive topics when collecting pregnancy outcomes and mortality data in demographic and health surveys. For researchers collecting maternal mortality data, it highlights the potential shortcomings of the sibling history methodology.

What maternal morbidities are and what they mean for women: A thematic analysis of twenty years of qualitative research in low and lower-middle income countries

Background

With an estimated 27 million annual incidents of maternal morbidity globally, how they are manifested or experienced is diverse and shaped by societal, cultural and personal influences. Using qualitative research to examine a woman's perception of her pregnancy, its complications, and potential long-term impact on her life can inform public health approaches and complement and inform biomedical classifications of maternal morbidities, historically considered a neglected dimension of safe motherhood. As part of the WHO’s Maternal Morbidity Working Group’s efforts to define and measure maternal morbidity, we carried out a thematic analysis of the qualitative literature published between 1998 and 2017 on how women experience maternal morbidity in low and lower-middle income countries.

Results and conclusions

Analysis of the 71 papers included in this study shows that women’s status, their marital relationships, cultural attitudes towards fertility and social responses to infertility and pregnancy trauma are fundamental to determining how they will experience morbidity in the pregnancy and postpartum periods. We explore the physical, economic, psychological and social repercussions pregnancy can produce for women, and how resource disadvantage (systemic, financial and contextual) can exacerbate these problems. In addition to an analysis of ten themes that emerged across the different contexts, this paper presents which morbidities have received attention in different regions and the trends in researching morbidities over time. We observed an increase in qualitative research on this topic, generally undertaken through interviews and focus groups. Our analysis calls for the pursuit of high quality qualitative research that includes repeat interviews, participant observation and triangulation of sources to inform and fuel critical advocacy and programmatic work on maternal morbidities that addresses their prevention and management, as well as the underlying systemic problems for women’s status in society.

“Machamba não é trabalho!”: HIV/SIDA e Produção Agrícola no centro de Moçambique

Resumo: O objetivo deste artigo é explorar como as políticas de cuidados e tratamento de HIV/SIDA e as atitudes de alguns profissionais de saúde afectam a possibilidade de que os pacientes, em particular as mulheres, cumpram com os requisitos da terapia antirretroviral e prossigam o tratamento em Moçambique (Manica e Maputo). Concentro-me na desigualdade em termos da invisibilidade da agricultura familiar e da diversificação de meios de sustento sugerindo que: a) as políticas e o tratamento do HIV/SIDA não tomam em conta as condições de vida dos pacientes que pretendem servir. Os serviços de saúde não consideram a flexibilidade exigida pela combinação de diversos meios de sustento por parte dos pacientes; b) a invisibilidade e a desvalorização da agricultura de pequena escala diminuem as possibilidades das mulheres de cumprir com as exigências do tratamento, com consequências para a adesão ao tratamento e, por conseguinte, com graves consequências para a sua saúde e prolongamento da sua vida.

Avoiding a "big" baby: Local perceptions and social responses toward childbirth-related complications in Menabe, Madagascar

In Madagascar, a country where over 60% of deliveries are not attended by a healthcare professional, late or inadequate responses to complications during childbirth account for a great number of maternal deaths. In this article, we analyse local perceptions of birth-related risks and strategies used to avoid these risks or manage complications of childbirth. We conduct this analysis in light of the social meanings of childbirth and the social expectations placed upon women in a context of socio-economic vulnerability and a challenged public health system. We conducted two separate studies in the district of Morondava (Menabe region) in June 2014 and March 2015, comprising semi-directive interviews with 111 people (59 mothers, 18 members of their immediate entourage and 34 institutional or healthcare stakeholders), and eight focus groups discussions - two with community leaders, and six with fathers. The results show that the social pressure exerted on women to give birth without complications leads them to practices aimed at avoiding a "big" baby including dietary restrictions, physical activity, and refusal of iron supplementation intake. During pregnancy, women are usually accompanied by a traditional birth attendant or matron (reninjaza). Further, they use the public health system by attending antenatal consultations. However, women are reluctant to deliver in a health facility, where the practices of health professionals are in discordance with the social realities of women and local beliefs around childbirth. If complications arise, they are explained by social causes. The parturient woman is only taken to a healthcare facility after carrying out rituals and if the problems do not resolve themselves. These findings support recommendations to reduce the cultural distance between health workers and childbearing women, strengthen the collaborations with reninjazas, and inform women and their decision makers (mother, reninjaza, spouse) about nutrition during pregnancy and signs of complications.

The Winners of Socialism: Fighting Infertility in Pronatalist Romania

Drawing from interviews and life histories, I consider the singular reproductive trajectories of women who fought infertility during the enforced pronatalist policies of the late communist era in Romania. I aim to explore the role of fine-grained ethnography in revealing both the localized mechanisms of reproductive governance and the diverse subjectivities produced by citizens' encounters with biopower. I argue that, through an analysis of these ethnographic cases, we can further conceptualize reproductive vulnerability as an intersubjective notion. In addition, women's atypical stories give us a glimpse into the typical workings of the recording and reporting practices of the pronatalist regime.

Disentangling Family Life and Hair Pulling: Trichotillomania and Relatedness

Trichotillomania (hair pulling) remains a relatively unknown form of body-focused repetitive behavior (BFRB). Sufferers tend to conceal both the action and its effects from others because of stigmatization, which is strong in both public and domestic spheres. Negative responses from close family members can add significantly to the suffering. Based on fieldwork in the United Kingdom and United States, we explore how hair pulling troubles ties even among close family members. We show why ethnographic methods reveal impacts of hair pulling that structured assessments do not yet capture and argue for a more nuanced study of BFRBs through anthropologies of relatedness.

Vulnerable articulations: the opportunities and challenges of illness and recovery

Medical anthropology overwhelmingly reveals vulnerability as a problem of powerlessness. Vulnerable groups and individuals are those exposed to the pernicious effects of inequalities, injustices, and oppressive political realities. This largely pejorative stance, we argue, simplifies the place of vulnerability within human experience and in relation to the body, health and illness. By showcasing a range of interlocking vulnerabilities, this paper reveal the spectrum of positive and negative vulnerabilities that affect health and recovery. Through the concept of vulnerable articulations, this paper argues that health and illness experiences simultaneously create and require a range of different interconnected vulnerabilities, some of them harmful, and some of them life affirming. Ethnographically, this paper explore the concept of vulnerable articulations through two contrasting case studies: a group of British and New Zealand nuclear test veterans seeking compensation from the state, and clients of equine therapy in New Zealand. These case studies reveal that understanding human vulnerability requires a close attention to how people navigate between the diverse vulnerabilities that they face, and that attaining well-being often involves harnessing positive vulnerabilities in order to lessen the effects of damaging vulnerabilities.

Keeping secrets in the cloud: Mobile phones, data security and privacy within the context of pregnancy and childbirth in Tanzania

Growing evidence points to the potential value of mobile phone-based technologies ('mHealth') to help strengthen community health systems in low- and middle-income countries, but mHealth approaches also carry considerable risks with respect to data security, individual privacy, and confidentiality. We examined the perspectives of frontline community health workers and their female clients regarding data security and privacy within the context of an mHealth intervention to improve women's uptake of maternal health services from October 2013 to July 2014 in rural Tanzania. Qualitative findings demonstrate that the use of new technologies to capture health service user data during pregnancy and childbirth has both positive and negative impacts on perceptions of personal privacy and confidentiality. Women's concerns regarding privacy aligned closely with a belief that pregnancies and expected delivery dates must be kept secret, reflecting fears that pregnancy renders women vulnerable to witchcraft by jealous neighbors. Women also shared concerns that health workers' male partners could access their private information. Strong community-based engagement is recommended from the outset when developing a mHealth intervention to integrate beliefs and gender dynamics that may influence acceptability and implementation of new technologies.

Culture and Birth Outcomes in Sub-Saharan Africa: A Review of Literature

INTRODUCTION

Almost 830 women die daily in childbirth with 550 of those deaths occurring in sub-Saharan Africa. This region has the highest maternal mortality rates in the world with 546 deaths per 100,000 live births. Research must focus on understanding cultural beliefs and practices to improve maternal health outcomes. The purpose of this review is to provide evidence of relevant cultural beliefs and the impact on birth outcomes for women in sub-Saharan Africa.

METHOD

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the literature focused on 25 articles that defined, directly or indirectly, associations of cultural values, beliefs, and lifeways to pregnancy and birth from the perspective of women of childbearing age.

RESULTS

Three relevant categories emerged from the literature: birth outcomes, maternal care-seeking, and maternal culture care.

DISCUSSION

Women's voices and an understanding of cultural constructs of care are required to encourage the use of biomedical health system along with the use of indigenous practices.

A Qualitative Study of Substance use during Pregnancy: Implications for Reproductive Healthcare in Western Kenya

Women who use alcohol and drugs are often in their childbearing years, creating a need for integrated substance abuse and reproductive health services. However, our understanding of the social context and drivers of substance use during pregnancy, particularly in developing countries, is limited and largely unaddressed in clinical care. Our qualitative research explored the reproductive health of women of childbearing age who inject drugs and its implications for healthcare in Kisumu, Kenya. We used in-depth, semi-structured qualitative interviews with 17 women who inject drugs to explore reproductive health topics including knowledge, practices, and clinical interactions related to substance use during pregnancy. All but one woman had a prior pregnancy and two were pregnant during our study. Alcohol and drug use was prevalent throughout pregnancy, often described as a coping mechanism for stress. Women received mixed advice from family and social contacts regarding alcohol use during pregnancy, leading to differing perceptions of its health effects. Healthcare providers infrequently screened women for alcohol or drug use. Our analysis highlights the need for culturally appropriate alcohol and drug screening and counseling to be included in integrated reproductive health services in western Kenya.

Community perspectives on the determinants of maternal health in rural southern Mozambique: a qualitative study

Background

Mozambique has one of the highest rates of maternal mortality in sub-Saharan Africa. The main influences on maternal health encompass social, economic, political, environmental and cultural determinants of health. To effectively address maternal mortality in the post-2015 agenda, interventions need to consider the determinants of health so that their delivery is not limited to the health sector. The objective of this exploratory qualitative study was to identify key community groups’ perspectives on the perceived determinants of maternal health in rural areas of southern Mozambique.

Methods

Eleven focus group discussions were conducted with women of reproductive age, pregnant women, matrons, male partners, community leaders and health workers. Participants were recruited using sampling techniques of convenience and snow balling. Focus groups had an average of nine participants each. The heads of 12 administrative posts were also interviewed to understand the local context. Data were coded and analysed thematically using NVivo software.

Results

A broad range of political, economic, socio-cultural and environmental determinants of maternal health were identified by community representatives. It was perceived that the civil war has resulted in local unemployment and poverty that had a number of downstream effects including lack of funds for accessing medical care and transport, and influence on socio-cultural determinants, particularly gender relations that disadvantaged women. Socio-cultural determinants included intimate partner violence toward women, and strained relationships with in-laws and co-spouses. Social relationships were complex as there were both negative and positive impacts on maternal health. Environmental determinants included natural disasters and poor access to roads and transport exacerbated by the wet season and subsequent flooding.

Conclusions

In rural southern Mozambique, community perceptions of the determinants of maternal health included political, economic, socio-cultural and environmental factors. These determinants were closely linked with one another and highlight the importance of including the local history, context, culture and geography in the design of maternal health programs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-016-0217-x) contains supplementary material, which is available to authorized users.

The costs of 'free': Experiences of facility-based childbirth after Benin's caesarean section exemption policy

As one of many similar policies in the region, in 2009 Benin launched a free c-section policy in publicly funded hospitals intended to decrease the barriers to facility delivery and the heavy financial burdens on women and their families. We conducted a qualitative study for eight months between 2012 and 2014 to understand women's experiences of care in maternity wards. We carried out semi-structured interviews with 30 women who had delivered via c-section at five hospitals. Two of these hospitals became case study sites where in-depth research was undertaken that consisted of participant observation in each maternity ward and 32 further interviews with women who had complicated, vaginal and c-section deliveries. Overall, women continue to pay for care, both in the form of under-the-table payments to health workers and prescribed payments for services not covered by the policy, though they consider the costs reasonable compared to what the charges were before. Lifting the fees has facilitated conditions for midwives to alert doctors that the procedure might be needed. Partly because c-sections are still feared by most women, in one hospital this led to some women perceiving them as a threat if their labour was progressing more slowly. Implementation of the policy differed greatly between the two case study hospitals. We conclude that some burdens on women's access to care have been addressed but deterrents remain to the improved perception of quality of care on the part of women. Findings detail how important context is to the implementation of the policy, and suggest that similar user-fee removal policies should be accompanied by other measures addressing staff management and quality of care.

The Importance of Blood Is Infinite: Conceptions of Blood as Life Force, Rumours and Fear of Trial Participation in a Fulani Village in Rural Gambia

BACKGROUND

Clinical trials require high levels of participation and low drop-out rates to be successful. However, collecting blood samples from individuals recruited into clinical trials can be challenging when there is reticence about blood-taking. In addition to concerns regarding the feasibility of medical research, fears of 'blood-stealing' and 'blood-selling' have ethical implications related to cultural sensitivity and informed consent. This study explores anxieties around blood-taking during a malaria treatment trial in the Gambia.

METHODS

This case study is based on ethnographic research in one theoretically selected village due to the high reticence to screening for the clinical trial 'Primaquine's gametocytocidal efficacy in malaria asymptomatic carriers treated with dihydroartemisinin-piperaquine' carried out in the Gambia between 2013 and 2014. Data collection tools included in-depth interviews, participant observation, informal conversations and group discussions.

RESULTS

In total only 176 of 411 habitants (42%) in the village accepted having a bloodspot taken to screen for malaria. Although trial recruitment was initially high in the village, some families refused screening when rumours started spreading that the trial team was taking too much blood. Concerns about 'loss of blood' were equated to loss of strength and lack of good food to replenish bodily forces. Families in the study village were concerned about the weakness of their body while they had to harvest their crops at the time of recruitment for the trial.

CONCLUSION

A common recommendation to prevent and avoid rumours against public health interventions and trials is the provision of full and consistent information during the consent procedure, which is assumed to lead to more accurate knowledge of the purpose of the intervention and increased trial participation. However, even when information provision is continuous, the emergence of rumours can be related to times of uncertainty and perceptions of vulnerability, which are often a reflection of structural inequalities and diverging value orientations between communities and public health institutions.

Barriers and facilitators to health care seeking behaviours in pregnancy in rural communities of southern Mozambique

BACKGROUND

In countries, such as Mozambique, where maternal mortality remains high, the greatest contribution of mortality comes from the poor and vulnerable communities, who frequently reside in remote and rural areas with limited access to health care services. This study aimed to understand women's health care seeking practices during pregnancy, taking into account the underlying social, cultural and structural barriers to accessing timely appropriate care in Maputo and Gaza Provinces, southern Mozambique.

METHODS

This ethnographic study collected data through in-depth interviews and focus group discussions with women of reproductive age, including pregnant women, as well as household-level decision makers (partners, mothers and mothers-in-law), traditional healers, matrons, and primary health care providers. Data was analysed thematically using NVivo 10.

RESULTS

Antenatal care was sought at the heath facility for the purpose of opening the antenatal record. Women without antenatal cards feared mistreatment during labour. Antenatal care was also sought to resolve discomforts, such as headaches, flu-like symptoms, body pain and backache. However, partners and husbands considered lower abdominal pain as the only symptom requiring care and discouraged women from revealing their pregnancy early in gestation. Health care providers for pregnant women often included those at the health facility, matrons, elders, traditional birth attendants, and community health workers. Although seeking care from traditional healers was discouraged during the antenatal period, they did provide services during pregnancy and after delivery. Besides household-level decision-makers, matrons, community health workers, and neighbours were key actors in the referral of pregnant women. The decision-making process may be delayed and particularly complex if an emergency occurs in their absence. Limited access to transport and money makes the decision-making process to seek care at the health facility even more complex.

CONCLUSIONS

Women do seek antenatal care at health facilities, despite the presence of other health care providers in the community. There are important factors that prevent timely care-seeking for obstetric emergencies and delivery. Unfamiliarity with warning signs, especially among partners, discouragement from revealing pregnancy early in gestation, complex and untimely decision-making processes, fear of mistreatment by health-care providers, lack of transport and financial constraints were the most commonly cited barriers. Women of reproductive age would benefit from community saving schemes for transport and medication, which in turn would improve their birth preparedness and emergency readiness; in addition, pregnancy follow-up should include key family members, and community-based health care providers should encourage prompt referrals to health facilities, when appropriate.

TRIAL REGISTRATION

NCT01911494.

Factors affecting attendance at and timing of formal antenatal care: results from a qualitative study in Madang, Papua New Guinea

BACKGROUND

Appropriate antenatal care (ANC) is key for the health of mother and child. However, in Papua New Guinea (PNG), only a third of women receive any ANC during pregnancy. Drawing on qualitative research, this paper explores the influences on ANC attendance and timing of first visit in the Madang region of Papua New Guinea.

METHODS

Data were collected in three sites utilizing several qualitative methods: free-listing and sorting of terms and definitions, focus group discussions, in-depth interviews, observation in health care facilities and case studies of pregnant women. Respondents included pregnant women, their relatives, biomedical and traditional health providers, opinion leaders and community members.

RESULTS

Although generally reported to be important, respondents' understanding of the procedures involved in ANC was limited. Factors influencing attendance fell into three main categories: accessibility, attitudes to ANC, and interpersonal issues. Although women saw accessibility (distance and cost) as a barrier, those who lived close to health facilities and could easily afford ANC also demonstrated poor attendance. Attitudes were shaped by previous experiences of ANC, such as waiting times, quality of care, and perceptions of preventative care and medical interventions during pregnancy. Interpersonal factors included relationships with healthcare providers, pregnancy disclosure, and family conflict. A desire to avoid repeat clinic visits, ideas about the strength of the fetus and parity were particularly relevant to the timing of first ANC visit.

CONCLUSIONS

This long-term in-depth study (the first of its kind in Madang, PNG) shows how socio-cultural and economic factors influence ANC attendance. These factors must be addressed to encourage timely ANC visits: interventions could focus on ANC delivery in health facilities, for example, by addressing healthcare staff's attitudes towards pregnant women.

Doctors and vampires in sub-Saharan Africa: ethical challenges in clinical trial research

Collecting blood samples from individuals recruited into clinical research projects in sub-Saharan Africa can be challenging. Strikingly, one of the reasons for participant reticence is the occurrence of local rumors surrounding "blood stealing" or "blood selling." Such fears can potentially have dire effects on the success of research projects--for example, high dropout rates that would invalidate the trial's results--and have ethical implications related to cultural sensitivity and informed consent. Though commonly considered as a manifestation of the local population's ignorance, these rumors represent a social diagnosis and a logical attempt to make sense of sickness and health. Born from historical antecedents, they reflect implicit contemporary structural inequalities and the social distance between communities and public health institutions. We aim at illustrating the underlying logic governing patients' fear and argue that the management of these beliefs should become an intrinsic component of clinical research.

Lessons learned in Liberia: preliminary examination of the psychometric properties of trust and teamwork among maternal healthcare workers

BACKGROUND

Post-conflict Liberia has one of the fastest growing populations on the continent and one of the highest maternal mortality rates among the world. However, in the rural regions, less than half of all births are attended by a skilled birth attendant. There is a need to evaluate the relationship between trained traditional healthcare providers and skilled birth attendants to improve maternal health outcomes. This evaluation must also take into consideration the needs and desires of the patients. The purpose of this pilot study was to establish the validity and reliability of a survey tool to evaluate trust and teamwork in the working relationships between trained traditional midwives and certified midwives in a post-conflict country.

METHODS

A previously established scale, the Trust and Teambuilding Scale, was used with non- and low-literate trained traditional midwives (n=48) in rural Liberia to evaluate trust and teamwork with certified midwives in their communities. Initial results indicated that the scale and response keys were culturally inadequate for this population. A revised version of the scale, the Trust and Teamwork Scale - Liberia, was created and administered to an additional group of non- and low-literate, trained traditional midwives (n=42). Exploratory factor analysis using Mplus for dichotomous variables was used to determine the psychometric properties of the revised scale and was then confirmed with the full sample (n=90). Additional analyses included contrast validity, convergent validity, and Kuder-Richardson reliability.

RESULTS

Exploratory factor analysis revealed two factors in the revised Trust and Teamwork Scale - Liberia. These two factors, labeled trust and teamwork, included eleven of the original eighteen items used in the Trust and Teamwork Scale and demonstrated contrast and convergent validity and adequate reliability.

CONCLUSIONS

The revised scale is suitable for use with non- and low-literate, trained traditional midwives in rural Liberia. Continued cross-cultural validation of tools is essential to ensure scale adequacy across populations. Future work should continue to evaluate the use of the Trust and Teamwork Scale - Liberia across cultures and additional work is needed to confirm the factor structure.

Exposure and exclusion: disenfranchised biological citizenship among the first-generation Korean Americans

Based on fieldwork with a highly uninsured and underinsured Korean American population, this article maps how the current healthcare system in the United States disenfranchises those of marginal insurance status. The vulnerability of these disenfranchised biological citizens is multiplied through exposure to disproportional health risks compounded by exclusion from essential healthcare. The first-generation Korean Americans, who commonly work in small businesses, face the double burden of increased health risks from long, stress-laden work hours and lack of access to healthcare due to the prohibitive costs of health insurance for small business owners. Even as their health needs become critical, their insurance status and costly medical bills discourage them from visiting healthcare institutions, leaving Korean Americans outside the "political economy of hope" (Good, Cult Med Psychiatry 52:61-69, 2001). Through an ethnographic examination of the daily practice of doing-without-health among a marginalized sub-group in American society, this paper articulates how disenfranchised biological citizenship goes beyond creating institutional barriers to healthcare to shaping subjectivities of the disenfranchised.

An analysis of two indigenous reproductive health illnesses in a Nahua community in Veracruz, Mexico

BACKGROUND

This article describes the local concepts indigenous Nahua women hold regarding their reproduction. Specifically it provides a description of two indigenous illnesses--isihuayo and necaxantle, it discusses their etiology, symptoms, and treatments, and it analyzes them within the local ethnomedical framework and sociopolitical context. A perception of female vulnerability is shown to be an underlying shaper of women's experiences of these illnesses.

METHODS

This research took place in a small Nahua village in Mexico. Qualitative data on local perceptions of these illnesses were collected by a combination of participant observation and interviews. Ethnobotanical data was obtained through interviews, and medicinal plants were collected in home gardens, fields, stream banks, and forested areas. The total study population consisted of traditional birth attendants (N = 5), clinicians (N = 8), and laywomen (N = 48).

RESULTS

Results showed that 20% of the village women had suffered from one or both of these illnesses. The article includes a detailed description of the etiology, symptoms, and treatments of these illnesses. Data shows that they were caused by mechanical, physical, and social factors related to a woman's weakness and/or lack of support. Traditional birth attendants often treated women's illnesses. Five medicinal plants were salient in the treatment of these illnesses: Ocimum basilicum L., Mentzelia aspera L., Pedilanthus tithymaloides (L.) Poit., and Piper umbellatum L. were used for isihuayo, while Solanum wendlandii Hook f. was used for necaxantle.

CONCLUSIONS

The research on these two ethnomedical conditions is a useful case study to understanding how indigenous women experience reproductive health. Reproductive health is not simply about clinically-based medicine but is also about how biomedicine intersects with the local bodily concepts. By describing and analyzing indigenous women's ill health, one can focus upon the combination of causes--which extend beyond the physical body and into the larger structure that the women exist in.

Traditional healers and laypeople: a qualitative and quantitative approach to local knowledge on medicinal plants in Muda (Mozambique)

ETHNOPHARMACOLOGICAL RELEVANCE

Through this study, relevant information was gathered on the knowledge about medicinal remedies in some rural communities of Muda (central Mozambique). The use of 198 different medicinal plants has been recorded and a significant number of medicinal species and uses new for Africa and particularly for Mozambique has been detected. Our investigation appears to be the first comparing knowledge about medicinal plants between laypeople and traditional healers and also between the two kinds of healers (curandeiros and profetas).

MATERIALS AND METHODS

Ethnobotanical data were gathered through semi-structured interviews with 67 informants: 9 curandeiros (traditional healers believed to be guided by spirits), 12 profetas (independent Pentecostal churches "prophets" healing both souls and bodies) and 46 untrained lay villagers. Data were entered in a data base and processed, also by means of suitable quantitative indexes.

RESULTS

A total of 546 citations were recorded for 198 different ethnospecies (i.e. basic ethno-taxonomical units). The species with the highest cultural value (estimated with Cultural Importance index) resulted to be Ximenia caffra (CI=0.224), Zanha golungensis (CI=0.194) Vernonia colorata (CI=0.149) and Ozoroa reticulata and Holarrhena pubescens (both with CI=0.134). Eight out of the 162 identified plants mentioned by the informants were not previously recorded as medicinal plants in Africa: Cissus bathyrhakodes, Clematis viridiflora, Combretum goetzei, Dioscorea cochleari-apiculata, Grewia pachycalyx, Indigofera antunesiana, Ipomoea consimilis, Tricliceras longipedunculatum. More than half of the species reported by our informants and already known as medicinal in Africa resulted to be newly documented for Mozambique. Comparing the mean number of species known by each informant group, statistically significant differences were observed both between curandeiros and laypeople and between profetas and laypeople. No significant differences emerged instead between curandeiros and profetas. Yet, even laypeople proved to hold quite a good knowledge about medicinal remedies; women in particular use several different plants to heal common diseases of the whole family, mostly for children and female health problems.

CONCLUSIONS

The high number of plants and uses recorded demonstrates that in the study area ethnobotanical knowledge is still quite rich and alive. The finding of many medicinal plants and uses new for Mozambique or even Africa shows the importance of recording this knowledge before it vanishes, also as a basis for further investigations on possible pharmacological properties of local plants. The lack of health infrastructures in Muda results in the need for lay villagers of acquiring and developing a rather high degree of knowledge about plants remedies; in a different interaction between healers and lay villagers, compared to urban areas; ultimately, in a different distribution and wider spread of traditional knowledge on medicinal plants.

Cultural childbirth practices, beliefs, and traditions in postconflict Liberia

In this qualitative study we used an interpretive, critical ethnographic approach to provide an understanding of childbirth and maternal illness and death in Liberia through the lens of women, families, and communities. We identified three major themes from the data: (a) secrecy surrounding pregnancy and childbirth; (b) power and authority; and (c) distrust of the health care system. The interpretive theory, Behind the House, generated from data analysis provides an understanding of the larger social and cultural context of childbirth in Liberia. Our findings provide a more complete understanding of the contextual factors that impact on the intractable problem of maternal mortality.

Malaria, danger, and risk perceptions among the Yao in rural Malawi

Findings from a study designed to discover how local understanding of malaria among Yao in Malawi relate to pregnancy risk definitions reveal that malaria in pregnancy is not perceived as a major risk. Using extended ethnographic field research and multiple methods, we argue a shift from narrow single-disease approaches to malaria during pregnancy is required and document women's concerns about exposure to multiple vulnerabilities during pregnancy, including witchcraft, extramarital affairs, and multiple dangerous illnesses. Four dimensions are implicated in Yao perceptions of risk: perceived adverse consequences in pregnancy; ease of treatment and cure; transmission and agency to control; and type of risk (social-medical). We discuss implications and consider malaria program features needed to address the complexity of perceived vulnerabilities and living conditions in resource-poor settings.

Choosing early pregnancy termination methods in Urban Mozambique

Little is known about who chooses medication abortion with misoprostol and why. Women seeking early abortion in 5 public hospitals in Maputo, Mozambique were recruited in 2005 and 2006 to explore decision-making strategies, method preferences and experiences with misoprostol and vacuum aspiration for early abortion. Client screenings (n=1799), structured clinical surveys (n=837), in-depth exit interviews (n=70), and nurse focus groups (n=2) were conducted. Triangulation of qualitative and quantitative data revealed seemingly contradictory findings. Choice of method reflected women's heightened concerns about privacy, pain, quality of home support, HIV infection risk, sexuality, and safety of research participation. Urban Mozambican women are highly motivated to find early pregnancy termination techniques that they deem socially and clinically low-risk. Although 42% found vaginal misoprostol self-administration challenging and 25% delayed care for over a week to amass funds for user fees, almost all (96%) reported adequate preparation and comfort with home management. Women reported satisfaction with all methods and quality of care, even if the initial method failed or pain management or postabortion contraception were not offered. A more nuanced understanding of what women value most can yield service delivery models that are responsive and effective in reducing maternal death and disability from unsafe abortion.

Threats to safe motherhood in Honduran Miskito communities: local perceptions of factors that contribute to maternal mortality

Despite global initiatives to lower rates of maternal death, barriers to safe motherhood persist, particularly in socially and economically marginalized communities. This article describes the risks that women in Honduran Miskito villages encounter during pregnancy and childbirth. Ethnographic data are used to examine emic understandings of the underlying causes of maternal death. Participant observation, four community discussions, individual interviews with 218 women and five midwives, and a maternal mortality survey were conducted during November 2004 through November 2005. Case studies are drawn from the 55 death histories collected during the survey to illustrate the factors that contribute to maternal mortality. Community members identified poverty, gender inequality, witchcraft, and sorcery as major threats to safe motherhood. All of these factors influence women's health-related behaviors; and therefore, each issue deserves attention from public health officials. Designing appropriate interventions to improve maternal health depends on understanding the forces that increase women's vulnerability during pregnancy and childbirth. Local perspectives of risk, even when they diverge from biomedical understandings, point to specific needs, issues to address, and avenues for effective intervention.

Health interventions and the persistence of rumour: the circulation of sterility stories in African public health campaigns

Public health programmes have done enormous good in Africa and elsewhere in the global south, but have also been met with skepticism. This skepticism often takes the form of rumours about the motives or the results of the public health intervention. One recurrent theme in such rumours is the centrality of reproductive bodies (both male and female), and the perception that these bodies are being rendered sterile by toxic compounds given under the guise of improving health. Public health operations research has identified these rumours as significant obstacles to programme delivery, but they have been treated primarily as failures in communication, to be rectified by the provision of more accurate information. Using reports of such rumours from public health interventions in Africa, with emphasis on vaccines, I argue that these rumours are more than simply stories which are not true. The widespread rumour of sterility is a way of articulating broadly shared understandings about reproductive bodies, collective survival, and global asymmetries of power. I use Foucault's notion of biopolitics to theorize international public health programmes, and introduce the concept of counter-epistemic convergence to account for the ubiquity and persistence of sterility rumours.

"Controlling ourselves, by ourselves": risk assemblages on Malaysia's assembly lines

Since the early 1990s, the Malaysian government has identified factories as high risk for HIV and AIDS. Signaling epidemiological concerns over the rising rates of HIV among factory workers, a significant proportion of whom are women, the label also appeared to reconstitute stereotypes of factory women as dangerously sexual and of factories as immoral spaces. Drawing on ethnographic research in the export processing zones of Penang, Malaysia in the mid-1990s, I examine the meanings and experiences of HIV risk among factory women themselves. Data were analyzed using discourse and grounded theory methods, the former to identify women's multiple modes of rationalizing HIV risks, and the latter to theorize the sources and significance of women's HIV risk assemblages. The heuristic of assemblages as localized knowledge spaces helped to show that biomedical and socioreligious risk lexica operated not as fixed epistemological categories but as situational resources in women's risk scripts. Overall, women desired multiple risk knowledges to help them "control themselves by themselves," a project of reflexive self-shaping mediated by the diverse and discordant discourses of gender, ethnicity, and modernity in Malaysia that shaped how HIV risks were engendered and experienced.

The culture of condoms: culturally grounded variables and their association with attitudes to condoms

OBJECTIVE

To examine attitudes toward condoms and their association with culturally grounded beliefs among young South African adults.

METHODS

A questionnaire survey undertaken in three different locations (urban, rural, and mixed), including 1100 participants, and implementing both a cross-validational and a bootstrap multivariate design. Outcome measures were intention to use a condom at next sex and condom salience (i.e., confidence in the protective value of condoms). Culturally grounded predictors included traditional beliefs about illness, beliefs in ancestral protection, endorsement of AIDS myths, and mortality salience (CONTACT).

RESULTS

Participants exhibited strong endorsement of indigenous beliefs about illness and ancestral protection, and moderate endorsement of AIDS myths. Participants who viewed condoms as important for HIV prevention were more likely to show strong endorsement of both beliefs in ancestral protection and traditional beliefs about illness. Participants who strongly endorsed AIDS myths viewed condoms as less important and also had lower intention to use scores. Finally, participants who knew HIV positive people, and/or people who had died of HIV-related illnesses, had higher condom salience and higher intention to use scores.

CONCLUSIONS

Results challenge the assumption that culturally grounded variables are inherently adversarial in their relationship to biomedical models of HIV prevention, and offer insights into how traditional beliefs and cultural constructions of HIV/AIDS might be used more effectively in HIV education programs.