Factors that Affect Maternal Care Seeking Behaviour and theChoice of Practitioner(s) during Complications: the Case ofMang’anja Tribe in Malawi

7/27/2019 Factors that Affect Maternal Care Seeking Behaviour and theChoice of Practitioner(s) during Complications: the Case ofMang’anja Tribe in Malawi

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Factors that Affect Maternal Care Seeking Behaviour and the

Choice of Practitioner(s) during Complications: the Case of

Mang’ana !ri"e in Mala#iollins $.). *amawe

1&2+

1. ,epartment o ommunit Health& /lantre International 0niersit& P/ag 9!& /lantre& 3alawi

2. Parent and hild Health Initiatie (P4HI Research entre& P.$. /o5 #1"!"& 6ilongwe& 3alawi

+ -mail o the corresponding author8 amawe:gmail.com

A"stract

,espite the high prealence rate o maternal mortalit coupled with under-utilisation o health serices& little

attempt has ;een made in 3alawi to e5plore and document people<s understanding and ;elies a;out causes and

appropriate treatment o the ma=or complications that are medicall ;elieed to ;e the causes o maternal deaths.

4n dierence ;etween the insider<s and the ;iomedical perceptions o what is a serious maternal complication

is dangerous ;ecause it ma dela see>ing o liesaing care. ?his stud was thereore& designed to elicit and

e5plore the local e5planator associated with the ma=or ;iomedical cause o maternal mortalit (haemorrhageamong 3ang<an=a tri;e in 3alawi and how these inluence care see>ing ;ehaiour. ,escriptie @ualitatie

research design was adopted and data was collected using Aleinman<s Be5planator model interiew guide< rom

2C respondents. ?he indings generall suggest that ;eing aware o maternal danger signs is not enough to

proo>e a trip to the appropriate healer. Since it is the cause not the eect o the maternal complications that

determines care see>ing& a shit in approach o health education proided to pregnant women is recommended.

$e%#ords: 3alawi& maternal health& e5planator model& care see>ing& haemorrhage

&' ntroduction

In response to the high leel o aoida;le maternal deaths (C''& ''' per ear& the Sae 3otherhood Initiatie

(S3I& Da glo;al eort to reduce maternal mortalit E;F hal ; the ear 2'''G was launched oer 2' ear ago

(19!7 ; the orld /an> and two 0nited Nations (0N agencies (S3I& 2''7. ?he S3I is generall drien ;our ma=or pillars8 proision o amil planning& high @ualit antenatal care (4N& clean and sae delier& and

essential o;stetric care (S3I& 2''7. 4lthough progress has ;een noticed in some o these pillars& oerall& theS3I still ailed to achiee the goal it set (i;id. In 2'''& the 0N reairmed its desire to improe the lies o

people around the world with the setting o 3illennium ,eelopment oals (3,s. oal ie has similar

intentions as S3I onl that its target is to reduce the maternal mortalit ratio (33R ; 7CJ ;etween 199' and

2'1C. /ut with onl less than three ears to go& there is little hope that this goal will ;e realised as not enough progress has ;een registered (0N& 2'1'K 2'11.

4lthough maternal mortalit is unaccepta;l high in almost the whole deeloping world& su; Saharan 4rica is

the most aected area with oer hal o the deaths occurring in the region (0N& 2'11. 3alawi is one o the su;

Saharan countries with high maternal mortalit ratio (33R. 4ccording to the 2'1' 3alawi ,emographic and

Health Sure (3,HS& the countr<s 33R stood at "7C per 1''&''' lie ;irths& which is well a;oe the

aerage 33R or su; Saharan 4rica. In its @uest to reduce maternal deaths& the goernment o 3alawi throughthe 3inistr o Health is strongl committed to ;oth S3I and 3,C. In addition& the BRoad 3ap or

4ccelerating the Reduction o 3aternal and New;orn 3ortalit and 3or;idit in 3alawi< was drawn up in 2''C

to accelerate the attainment o the 3,C.,espite these eorts ; the goernment and other sta>eholders to improe the @ualit and accessi;ilit o

maternal health care serices& it has ;een noted that their utilisation in 3alawi remains er low. )or instance&3,HS (2'1' documented that onl a;out L"J o pregnant women ull patronise 4N& oer #'J o delieries

are still conducted outside health acilities and a;out L!J o women don<t receie the much needed postnatal

care. ?he implication o this is that the said eorts are not ielding the intended results o reducing maternal

mortalit. )or instance& against seeral goernment and sta>eholder commitments& 33R increased in 3alawi

rom "2' in 1992 to around 1''' ;etween 199" and 2''L (National Statistic $ice ENS$F& 2'''K 2'1'. It is not

ull >nown wh man pregnant women don<t see> ;iomedical care ;ut one recognisa;le act is that little or noattention has ;een gien to how women in speciic cultures in 3alawi perceie or deine medical o;stetric

pro;lems. hite (2''2 noted that Din some settings& the dierence ;etween the emic& or cultural insider<s

perception& and the ;iomedical perception o what is a serious o;stetrical pro;lem ma dela liesaing careG.

?his stud thereore wanted to elicit and e5plore local understanding (e5planator model associated with one o

the ma=or ;iomedical causes o maternal mortalit in 3alawi (haemorrhage and how these inluence caresee>ing ;ehaiour. 3ore speciicall& the stud wanted to (1 e5amine how people iew the state o ;eing



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pregnant& (2 esta;lish the local pesought during complications and wh

' !heoretical "ase

'&' *+planator% modelAleinman (19!' articulated one o

Be5planator model< (3& which ;as Dthe notions a;out an episode o

clinical processG (Aleinman& 19!'&

progress o the illness and how th

patients and practitioners& and the

it has occurredK what the condition

approach recognises the importancetreating illnesses.

'' llness causation

hen conceptualising their 3s& p

people. $n top o the ;iomedical

phsiological changes in the ;odcausation& which ascri;e ill-health t

;lamed or not ta>ing good care o

the natural worldK in particular& the

the aetiolog is sometimes placed i

supernatural world is not sparedK ill

and spirits. )or instance& illness is

theories are not mutuall e5clusi

causes.

)igure 18 onceptual ramewor> sh

turn& dictate the appropriate tpe (s

,' Methods

,'&' Setting of the stud%?he ieldwor> or this stud was co

located in the southern part o 4ric

to the west ; *am;ia. ?he countr

partitioned into 2! districts. It has t

(NS$& 2''!K ,HS& 2'1'. hi>hwgroups and it has one o the wors

;ecause it is the largest tri;e in the

deined ; the presence or a;sence

nline

19

rception o haemorrhage and (# understand the t.

the most important and popular concept in medic

asicall reeals how people ma>e sense o their ill-h sic>ness and its treatment that are emploed ; al

.1'C& the concept generall scrutinies how patients

thin> it should ;e treated. 5planator models (

roide their perception o ill-health in terms o8 the c

does to the ;od and the appropriate treatment (in

o patients< personal iews o their health pro;lem i

atients usuall ascri;e the aetiolog o their ill-healt

paradigm& which attri;utes the aetiolog o malad

(in>elman& 2''9K Helman (199' descri;es ouro the ollowing8 irstl& the indiidual patient. )or inisher diet& hgiene& smo>ing and others. Secondl& i

enironmental actors li>e climatic conditions (i.e. e

the social world. /lame here is put on sorcer& wit

-health can also ;e caused ; direct actions o supern

seen as a diine punishment or sinul ;ehaiour. H

;ut he is silent on how the illnesses are speciica

owing that it is the 3 that determines the aetiolog

o care.

nducted among 3ang<an=a ethnic group in hi>hwa

a. It is ;ordered to the north ; ?ananiaK to the sout

is diided into three regions (north& central and s

e population o around 1L million o which a;out !C

wa district is mainl composed o 3ang<an=a ("'Jmaternal health indicators in 3alawi. 3ang<an=a

area. No speciic illages were chosen in the districtK

the concerned ethnic group mem;ers and not geogr

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pe(s o maternal care

al anthropolog called

ealth. )ormall deinedl those engaged in the

interpret the cause and

3s are held ; ;oth

ause o the illnessK wh

elman& 2''9. ?he 3

diagnosing as well as

h to arious o;=ects or

to germs and or ;io-

ther theories o illnesstance& the indiidual isll-health is attri;uted to

cessie cold. ?hirdl&

chcrat and others. ?he

atural entities li>e gods

elman noted that these

ll ascri;ed to arious

o ill-health& which& in

wa& 3alawi. 3alawi is

h ; 3oam;i@ueK and

uth which are urther

J sta in the rural area

and Sena (#'J ethnics a group was chosen

the setting was simpl

phicall.





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,'' Stud% designIn order to elicit e5planator models rom respondents& a @ualitatie research design was preerred (,aid and

Sutton& 2'11. Interiew guides& which were designed ;ased on 4rthur Aleinman<s 197! interiew guide& were

deeloped. ?he guides ;asicall elicited three main themes a;out the maternal complications rom the patient<s

perspectie8 what causes it& how it aects them& and the possi;le treatment. 3ore speciicall& respondents wereas>ed a;out their iews a;out haemorrhage which is the main cause o maternal deaths in 3alawi and man

other deeloping countries (eu;;el& 2''"K 0N 2'1'& 2'11. In-depth interiews were the onl tool that wasused to collect data. ?he choice o this tool was purel on methodological grounds. )irstl& ; its nature& the

Aleinman<s e5planator model interiew guide its well with in-depth Interiews. In addition& the aim o the

research was to elicit indiidual e5planator models and that automaticall its well with in-depth interiews&

which are also good at drawing out an indiidual perspectie o an issue (/rman& 2''1.

,ata was collected in Mul 2'12 (three wee>s and ,ec - Man 2'1# (our wee>s in the same area. Participants

were mainl women who hae at least one child. In particular& the respondents were ten pregnant women& ten oldwomen& three traditional ;irth attendants and two traditional healers. ?he age range o the respondents ranged

rom 1C to CC ears. Participants were purposeull recruited and interiewed in their illages. 4ll the interiews

were done in the main local language (hichewa.

,',' -ata management

4ll the interiews were transcri;ed and translated to nglish. ?he Nio @ualitatie data analsis sotware wasused throughout the data analsis process. 4ll the transcripts were irst transerred to Nio and read in greatdetail in order to identi an recurrent pattern. 4ll items relating to the same topic were coded to similar nodes.

?his was ollowed ; a5ial coding& which connect the su;stantie codes a;oe (Punch& 199!. 4naltical

actiities were conducted in a circular wa& where; tas>s were repeated& oerlapped& or conducted

simultaneousl which ena;led deep penetration o the data.

,'.' *thical considerations/eore ieldwor>& the stud proposal went through a ormal assessment ; the ,urham anthropolog<s ethics

committee in 0nited Aingdom. In 3alawi& the stud was also dul approed ; the National Health Science

Research ommittee (NHSR as well as district and communit authorities. Inormed consent was also

administered to all the respondents.

.' Findings

.'&' !he local perception to#ards the state of "eing pregnant Notwithstanding the high degree o importance that almost all communities gie to children and pregnanc&

;eing pregnant is generall seen as a dangerous status. en the two popular local names or pregnanc

B pakati< (lie or death and Bwodwala< (sic> woman clearl signal how pregnanc is perceied as clariied ;

one traditional healer8 DWe call them ‘sick women’ because pregnancy come with so many illnesses as I have

already talked about. These illnesses disappear once a woman has delivered. Therefore the whole period of pregnancy the woman is a patient .G 4dditionall& all respondents said that pregnant women are relatiel

ulnera;le to ill-health. 4 oung pregnant woman reasoned li>e this8 Dbecause the thing [foetus] inside me is

etracting energy from my body! I am always weak compared to the time I was not pregnant" that is why I

fre#uently suffer from fever .G

3ore speciicall& respondents stated that B $uchepamaga%i< (anaemia& 3alaria& ;leeding& miscarriage& poert&

and iolence against women are the most serious maternit pro;lems. 4lmost eer woman mentioned Bshortage

o ;lood< as a serious maternal pro;lem and arious causes were cited such as e5cess sunshine& malaria& poor

diet& witchcrat and oerwor>ing. $ne woman said8 DWhen it is hot! our blood boils and evaporates &ust likeboiling water .G 3ost women noted that shortage o ;lood is er dangerous ;ecause a pregnant woman needs

more ;lood to share with the oetus and i the ;lood is not enough& either the woman or the oetus (or ;oth

would die. ?he word 3alaria is mostl used interchangea;l with eer. 3os@uitoes& rainall& oerwor>ing and

the pregnanc itsel are the ma=or causes o 3alaria that were mentioned ; the respondents. 3an women also

reported that iolence against them& oten perpetrated ; their own hus;ands in orm o ;eating& is a serious

pro;lem. 3ore than hal o the women were once ;eaten ; their hus;ands during pregnanc. ?his is regarded as

a serious issue ;ecause it can lead to o;stetric complications as noted ; one woman8 D some [women] are beaten

while pregnant! so when the time to deliver comes they miscarry because of being beaten. 'ome also suffer from

abdominal pain due to the same problem of being beaten.G $ther pro;lems that were mentioned include8

headache& hunger& diiness& stomach-ache& swelling& painul legs& nausea& omiting& ;lurred ision& ainting&

high ;lood pressure& witchcrat and caesarean section.

4lthough man women consider the pro;lems a;oe er distur;ing& still& most o them said that these pro;lems

are part o pregnanc that a woman cannot do without. ?hese pro;lems are seen to ;e so attached to pregnancto the e5tent that some o them are thought to ;e signs o pregnanc. hen as>ed how she discoered her





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pregnanc& one woman said& D I stopped menstruating! I was eperiencing nausea and vomiting! I suffered from (alaria and I was also feeling backache ....G

.'' /ocal perception of maor o"stetric pro"lem 0 1aemorrhage

4lthough haemorrhage is the leading cause o maternal mortalit in 3alawi (eu;;els& 2''"& er ew

respondents oluntaril mentioned it as one o the maternal complications. Howeer& this did not stop theresearchers rom pro;ing their perception or understanding o the same. 4 closer loo> at haemorrhage rom the

participant<s perspectie reealed that there are two sides o ;leeding during pregnanc as well as postpartum.hile some respondents ;elieed that it is a health pro;lem& the ma=orit loo> at it rom another angle.

$n one hand& ;leeding is seen as sering important unctions that help to sustain pregnanc. /leeding during the

earl months o pregnanc is thought to ;e a ;loom that sweeps the menstruation letoers rom preious months

so as to create a good atmosphere or the oetus to deelop. $ne old woman said D... blood is very dangerous" it

can kill the baby in the womb. Therefore! menstruating in the early months is important to remove all the

remaining blood in the woman’s uterus ....G 4part rom that& ;leeding during pregnanc is also seen assomething which women inherit rom their parents. Respondents argued that some women hae less sensitie

;odies which ta>e time to respond to pregnancK that is wh the continue menstruating8 D some women are &ust

insensitive to pregnancy so they continue menstruating .G

/leeding towards the end o pregnanc is perceied in a more similar wa to how it is seen in the earl months.

4 num;er o respondents reported that menses towards the end o pregnanc clear the ;irth canal or smoothdelier. 4lthough the ailed to mention the speciic things which need to ;e cleared& ;ut the insisted that thedelier passage needs to ;e cleaned ;eorehand8 D... the blood removes the dirt in the passage so that the thing

[the baby] should come out uncontaminated .G /ut not all women ;leed during pregnanc and I wondered how

come these women still delier health ;a;ies and one woman had a simple answer or me8 D yes! they don’t

bleed" but women have different ways of removing the dirt. )thers clear the passage through urine! vomits!

faeces! and fluids [discharged via vagina].G

Must li>e ;leeding during pregnanc& postpartum ;leeding also seres a unction. Respondents generall said that

;lood and all other wastes associated with the oetus needs to ;e remoed rom the ;od ater delier.

4ccording to the participants& i these things are not cleaned& a woman ma die ;ecause o what the called

Bmtayo< (rotten stu associated with oetus8 D... blood and foetus wastes that remain in the womb after delivery

are very dangerous. If left unclean! this stuff can kill a woman.G ?hereore& little ;leeding is seen as not haing

enough pressure to remoe these letoersK a local midwie said that Dwe epect them to bleed heavily for one or

two days then slowly may be for up five days.G It was also reported that there is a local remed or those whodon<t ;leed enough ater delier8 D... we insert a funnel in the vagina and water mied with herbs are poured

into the womb to clear the leftovers.G

$n the other hand& other respondents ac>nowledged that menstruating or ;leeding during pregnanc could ;e a

sign that something is wrong. 3an participants mentioned that it might ;e an indication that the pregnanc is

not sta;le. $ne o the traditional healers o;sered that ;leeding during pregnanc simpl means that the

pregnanc has ;een or a;out to ;e terminated. $ther participants noted that ;leeding during pregnanc is unsae

;ecause it ma lead to anaemia& D... I know bleeding is risky because it left the woman with too little blood to

share with the baby" so the baby can die.G

?hose who ;eliee that ;leeding seres a unction see it as a natural process& which needs neither e5planation

nor treatment. Howeer& around three ma=or causes o ;leeding emerged especiall rom those who see it as a

health pro;lem. )irstl& respondents said that it is as a result o poor diet. It was argued that a malnourished

pregnant woman has less strength to turn the ;lood into a oetus. ?hereore& the ailure or the roughness o the

ormation process o the oetus results in release o either all or some o the ;lood& which were supposed to ;eused to orm a oetus. ?his is sometimes ollowed ; miscarriage. Secondl& other respondents attri;uted it to

witchcrat. ?he ;elieed that ;ecause o personal reasons li>e =ealous& a woman ma ;e ;ewitched. $ne o the

local healers e5plained8 D... sometimes it is an act of witchcraft in our villages. 'ome evil spirits may &ust want to

kill the baby because of &ealousy or other things .G 6astl& others ;eliee that it is the ;rea>ing o ta;oos that lead

to ;leeding. )or instance& one old woman said8 Dduring ‘mwambowamimba’ *ceremony organised for first time

pregnant women+ we advised them when to stop seual intercourse. If they ignore this! then it may result in

bleeding because they disturb things inside.G

.',' !%pes of maternit% care sought during complication

.','&' 1ome remedies

3ost o the pro;lems which are not perceied to ;e serious or that are regarded as normal during pregnanc

rarel proo>ed a trip to an care proider. Home remedies or =ust a change o ;ehaiour is considered enough

to get rid o the pro;lem. )or instance& women reported that the did not see> an special care or pro;lems such

as omiting and nausea& swollen& headache and diiness ;ecause are not serious enough to warrant a caresee>ing trip. $ne woman had this to sa8 D... when serious problems appear we of course go to the hospital but





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not di%%iness and vomiting! these are not issues to worry about. We always know that they will disappear afterchildbirth.G hile ac>nowledging that these pro;lems are indeed minor& some women still reported adopting

sel-medication. $ne woman said this8 D... it may be costly to go to the hospital with these small issues! most time

we &ust buy ‘,anado’ *painkiller+ from nearby shops.G 6i>ewise& almost all the women who ;eliee that

haemorrhage is normal reported that the did not see> an speciic care when the e5perienced it during their preious pregnancies. Howeer& ew women mentioned that the went to the hospital to get ;lood pills ;ecause

the were araid that the would not hae enough ;lood to >eep their pregnanc. $thers emploed sel-medication8 D... I was worried that I would have run short of blood. 'o I used ‘avocado leaves’ and they helped

to restore my blood level .G hange o ;ehaiour or liestle also emerged as a common therap or a num;er o

pro;lems.

.','' !raditional care

4ll respondents agreed that man women use traditional medicine to treat or preent arious maternit pro;lems.

3an women reported that the isit the traditional healers to see> help when the suspect that their pregnancwas not sta;le. Seeral women praised the traditional her;s as er eicient in preenting pregnanc loss due to

witchcrat. $ne woman recalled this8 Dwhen I started bleeding! I knew that this pregnancy would not survive if I

&ust sit down. 'o I went to get the herbs to settle it .G Some women also reported using Bmchape< (washer to clean

their wom;s when the were suering rom a;dominal pain. ?his is to clear the menstruation letoers& which

are thought to ;e the cause o a;dominal pro;lems during pregnanc. Must li>e wastes need to ;e remoed aterdelier& so are wastes ater a miscarriagea;ortion has occurred. ?raditional midwies reported that the oercleaning serices to women& which also include protection against uture miscarriages. 4dditionall& it was also

reported that sometimes traditional help is sought as an alternatie or complementar to ;iomedicine ;ecause

some pro;lems respond ;etter to traditional than western medicine.

.',',' Biomedical care

4lmost all women reported that the sought maternit care at least once at the hospital either during current or

preious pregnancies. ?he superiorit& relia;ilit and eectieness o the western medicine are some o the

reasons that attracted women to see> ;iomedical care. 3an respondents o;sered that it is onl at the medical

acilities where high standard tpe o care is proided. Some went as ar as saing that local healers and

midwies >now nothing and that the =ust want to earn a liing rom cheating people8 D... these old women *local

midwives+ are liars! they don’t know how to treat problems but they still insist to help people. I can’t go there!

never. The clinicians at the hospital are the right people to consult because they are well-trained in science and

they know what they are doing not these uneducated witches [traditional healers].G4lthough man women said that the see> care at the hospitalK most o them do not >now wh the go there.

hen as>ed wh the go to antenatal care& most pregnant women responded that the =ust go there ;ecause the

are supposed toK no speciic clinical reasons were proided. In act& the were all aware that the need to isit the

hospitalK ;ut or them& the isits are =ust ha;itual. It was also noted that communities hae put in place penalties

that are gien to women who do not see> medical care. ,uring the interiews& it was re@uentl reported that all

women who ail to see> medical care and conse@uentl delier in their illages are lia;le to a penalt in orm o

a goat or the e@uialent in cash.

2' -iscussion

?his discussion e5amines our o ie main @uestions that e5planator models see> to e5plain8 course o illness

(i.e. seerit& aetiolog& pathophsiolog and treatment (Aleinman& 19!'.

2'&' 3eneral perception of pregnanc%: normalit% of complications

?he stud has reealed that pregnanc is perceied in arious was among the 3ang<an=a. 4lthough a source ohonour to parents& it has ;een noted that pregnanc is also one o the most dangerous episodes in the lies o

women. ?he names B pakati< and Bwodwala< that pregnant women are >nown ; spea> clearl a;out their

situation. ?his o;seration is not newK Helman (199' also declared that in all societies& pregnanc is seen as a

ris> period which calls or special ceremonies& practices and ta;oos. /ut surprisingl& aside rom complaining

a;out the dangers that the pregnanc poses& women were also @uic> to point out that the pro;lems are normal.

?his is a distur;ing o;seration ;ecause these pro;lems are at the same time regarded as lie threatening. 4

closer loo> at this conusion ;rings to mind in>elman<s (2''9 remar>s that illnesses are e5perienced and

interpreted within a cultural conte5t& which deines the seriousness o the condition. ?his ;asicall implies that

although the pregnanc is generall considered as a Blie or death< situation& at the same time the threats it poses

has ;een culturall internalised and normalised. ith this normalisation& it should not ;e surprising that een

when their lie is in danger& pregnant women among the 3ang<an=a people do not see> care to remed the

maternal complications the e5perience.





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2'' 1aemorrhage: the necessar% evilIt was also interesting to note that not eerone perceies haemorrhage as a pro;lem. 3an participants argued

that ;leeding seres important unctions in their ;odies. It is ;asicall not >nown how these e5planations come

a;out ;ecause een the respondents themseles were una;le to locate the source. Howeer& it was clear that this

>nowledge is culturall accepta;le and it is passed on rom one generation to another through ceremonies suchas Bmwambowamimba<. It has ;een esta;lished that ;leeding is seen as proiding cleaning serices to the uterus

in the earl months& and to the ;irth passage& in the last ew wee>s o pregnanc. 4nd ater delier& the unctionis to clear the wastes that the ;a; let ;ehind in the uterus. In act& little ;leeding is seen as unhealth ;ecause it

lac>s enough pressure necessar to remoe the dirt. Similarl& hiwuie and $>olocha (2''1 reported that

>poma women in Nigeria go urther to induce ;leeding ater delier to ensure that their uterus is dul cleaned.

?hese o;serations dier slightl to what hite (2''2 ound among the Ahmer women in am;odia& who

;eliee that ;leeding during pregnanc seres to wash the ace o the ;a;. Howeer& the common perception o

;leeding among Ahmer& >poma and 3ang<an=a is that the all see it not as an o;stetrical pro;lem ;ut rather assering important unctions necessar to sustain pregnanc and the lie o the woman. ?hese o;serations are

er dangerous ;ecause the can hinder timel and appropriate care see>ing.

2',' Care seeking practices: Medical s%ncretism

hile man studies hae wor>ed on the assumption that ;iomedical is the onl tpe o care aaila;le to pregnant

women (urr& 199'K lei& 2''2K 3er O Harrison& 2''#& this stud has reealed that at least three sources omaternal care are aaila;le to women8 home remedies& traditional& and medical care. ?he most importanto;seration howeer& is not these tpes o care ;ut rather how the are chosen in times o need. ?he indings o

this stud conirm the la theories o illness causation that were put orward ; Helman (199'. ?he underlining

lin> is that the choice o care is largel dependent on the wa the illness is perceied. )or instance& illnesses

which were regarded as normal or less seere to women rarel proo>e a trip to an healer. Respondents

reported that illnesses li>e headache& ;lurred ision and swollen legs are normal in pregnanc and indeed er

ew o these cases were ta>en to the practitioner. ?his is in line with the health ;elie model (H/3& which

;asicall asserts that the perception o the seerit o the illness is one o the determining actors or care see>ing

;ehaiour (role& 2''C. Howeer& unli>e H/3& it has ;een noted that it is not onl the seerit o the illness

that matters ;ut also whether the treatment is re@uired at all since other illnesses though dangerous are

considered Bnormal< or Bnecessar<. ?his stud has showed that there are some maternal pro;lems that the

mang<an=a tri;e ;eliees need no action as delier itsel is considered the ultimate treatment.

It was urther noticed that most people who ascri;ed the o;stetrical pro;lems to witchcrat mentioned traditionalcare more oten than not as the appropriate treatment. 3ost o them argued that hospital is irreleant to their

pro;lems which were oten deined as either witchcrat or ta;oo ;ased. ?his pro;a;l stems rom the ;elie that

;iomedicine cannot successull diagnose or treat illnesses emanating rom witchcrat as o;sered ; hapman

(2''# and hiwuie O $>olocha (2''1 in 3oam;i@ue and Nigeria respectiel. /ut what is not >nown is

how the causes o these illnesses are deined as witchcrat ;ased or not. It is possi;le that some naturall caused

pro;lems are attri;uted to witchcrat there; delaing use o appropriate care. 3ore research on this is

recommended.

3an women also reported receiing antenatal and child;irth care rom the ;iomedical acilities. Howeer& what

is clear a;out ;iomedical care is that women ailed to =usti wh the sought the care or een to state the

importance o the serices the were gien. )urther e5ploration o this issue reealed that not all women see>

;iomedical care oluntarilK power and authorit o those in high positions orced them to utilise health acilities

through imposition o penalties. It is not >nown whether this is a sustaina;le strateg or not& urther research is

[email protected] general& although tpes o care are usuall discussed separatel (see hapman& 2''#K 4rps& 2''9& their

utilisation does not necessaril ollow the same trend. ?he indings o this stud hae conirmed the e5istence o

medical sncretism& the use o dierent >inds o treatment at the same time (Pool O eissler& 2''!.

4' Conclusions

Preious studies hae documented that raising awareness o women on the danger signs o o;stetrical pro;lems

is crucial or the realisation o sae motherhood and 3,C (see hite& 2''2K Hailu et al.& 2'1'K Pem;e et al.&

2''9. ?he assumption is that pregnant women ma see> appropriate care on time i the are amiliar with these

danger signs. Howeer& e5planator models elicited rom 3ang<an=a people suggest that ;eing aware o these

danger signs is not enough to proo>e a trip to the appropriate healer. )or instance& some o the danger signs are

also considered part and parcel o pregnanc normal. ?his stud has thereore& ailed to ind eidence that

>nowledge o ris> actors inluence women<s decision to see> appropriate care.

It has ;een o;sered that the insider<s deinition o appropriate care is not i5edK it is a unction o the deinitiono the illness itsel. )or instance& this stud has showed that women<s >nowledge o ;leeding as a dangerous





%ol.#& No.1!& 2'1#

2L

complication did not automaticall illicit a =ourne to a medical acilitK most o them reported utilising othermodes o healing. ?his stud thereore& has esta;lished that it is the perceied causes o the o;stetrical

complications em;edded in people<s e5planator models that determine whether care would ;e sought or not and

rom whom. Interestingl& the perceied causes o these complications are in turn aected ; the traditional

;elies and practices surrounding the issue o pregnanc& child;irth and postpartum. ?he e5istence o medicalsncretism also implies that although each complication has a targeted healer& other practitioners are also

consulted. Social& economic and political actors such as transport cost& aaila;ilit o acilities and goernment policies also pla an important role.

5' 6ecommendations

In order to improe utilisation o medical acilities& a shit in approach o health education proided to women is

recommended. Since it is the cause not the eect o the complications that determines care see>ing& women need

to ;e told the speciic causes o these complications and the underling phsiological processes in a wa thecan easil understand in order to improe care see>ing. 4uthorities can also ta>e adantage o the aaila;le local

structures li>e Bmwambowamimba< ceremon to delier messages to women and communities. /ut ;eore such

initiaties are put in place& there is a need to understand how the local e5planations o illness causation are

deeloped.

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