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Factors that Affect Maternal Care Seeking Behaviour and the Choice of Practitioner(s) during Complications: the Case of Mangan a !ri"e in Mala#i
(ollins $.). *amawe1&2+ 1. ,epartment o- (ommunit. Health& /lant.re International 0ni1ersit.& P2/ag 9!& /lant.re& 3alawi 2. Parent and (hild Health Initiati1e (P4(HI Research (entre& P.$. /o5 #1"!"& 6ilongwe& 3alawi + 7-mail o- the corresponding author8 -9amawe:gmail.com A"stract ,espite the high pre1alence rate o- maternal mortalit. coupled with under-utilisation o- health ser1ices& little attempt has ;een made in 3alawi to e5plore and document people<s understanding and ;elie-s a;out causes and appropriate treatment o- the ma=or complications that are medicall. ;elie1ed to ;e the causes o- maternal deaths. 4n. di--erence ;etween the insider<s and the ;iomedical perceptions o- what is a serious maternal complication is dangerous ;ecause it ma. dela. see>ing o- li-esa1ing care. ?his stud. was there-ore& designed to elicit and e5plore the local e5planator. associated with the ma=or ;iomedical cause o- maternal mortalit. (haemorrhage among 3ang<an=a tri;e in 3alawi and how these in-luence care see>ing ;eha1iour. ,escripti1e @ualitati1e research design was adopted and data was collected using Aleinman<s Be5planator. model inter1iew guide< -rom 2C respondents. ?he -indings generall. suggest that ;eing aware o- maternal danger signs is not enough to pro1o>e a trip to the appropriate healer. Since it is the cause not the e--ect o- the maternal complications that determines care see>ing& a shi-t in approach o- health education pro1ided to pregnant women is recommended. $e%#ords: 3alawi& maternal health& e5planator. model& care see>ing& haemorrhage &' (ntroduction In response to the high le1el o- a1oida;le maternal deaths (C''& ''' per .ear & the Sa-e 3otherhood Initiati1e (S3I & Da glo;al e--ort to reduce maternal mortalit. E;.F hal- ;. the .ear 2'''G was launched o1er 2' .ear ago (19!7 ;. the Horld /an> and two 0nited Nations (0N agencies (S3I& 2''7 . ?he S3I is generall. dri1en ;. -our ma=or pillars8 pro1ision o- -amil. planning& high @ualit. antenatal care (4N( & clean and sa-e deli1er.& and essential o;stetric care (S3I& 2''7 . 4lthough progress has ;een noticed in some o- these pillars& o1erall& the S3I still -ailed to achie1e the goal it set (i;id . In 2'''& the 0N rea--irmed its desire to impro1e the li1es opeople around the world with the setting o- 3illennium ,e1elopment Ioals (3,Is . Ioal -i1e 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 de1eloping world& su; Saharan 4-rica is the most a--ected area with o1er 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 Sur1e. (3,HS & the countr.<s 33R stood at "7C per 1''&''' li1e ;irths& which is well a;o1e the a1erage 33R -or su; Saharan 4-rica. In its @uest to reduce maternal deaths& the go1ernment o- 3alawi through the 3inistr. o- Health is strongl. committed to ;oth S3I and 3,IC. 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,IC. ,espite these e--orts ;. the go1ernment and other sta>eholders to impro1e the @ualit. and accessi;ilit. omaternal health care ser1ices& it has ;een noted that their utilisation in 3alawi remains 1er. low. )or instance& 3,HS (2'1' documented that onl. a;out L"J o- pregnant women -ull. patronise 4N(& o1er #'J o- deli1eries are still conducted outside health -acilities and a;out L!J o- women don<t recei1e the much needed postnatal care. ?he implication o- this is that the said e--orts are not .ielding the intended results o- reducing maternal mortalit.. )or instance& against se1eral go1ernment 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 no attention has ;een gi1en to how women in speci-ic cultures in 3alawi percei1e or de-ine medical o;stetric pro;lems. Hhite (2''2 noted that Din some settings& the di--erence ;etween the emic& or cultural insider<s perception& and the ;iomedical perception o- what is a serious o;stetrical pro;lem ma. dela. li-esa1ing careG. ?his stud. there-ore wanted to elicit and e5plore local understanding (e5planator. model associated with one othe ma=or ;iomedical causes o- maternal mortalit. in 3alawi (haemorrhage and how these in-luence care see>ing ;eha1iour. 3ore speci-icall.& the stud. wanted to (1 e5amine how people 1iew the state o- ;eing

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pregnant& (2 esta;lish the local perception o- haemorrhage and (# understand the t.pe(s o- maternal care sought during complications and wh.. )' !heoretical "ase )'&' *+planator% model Aleinman (19!' articulated one o- the most important and popular concept in medical anthropolog. called Be5planator. or. model< (73 & which ;asicall. re1eals how people ma>e sense o- their ill-health. ill health. )ormall. de-ined as Dthe notions a;out an episode o- sic>ness and its treatment that are emplo.ed ;. all those engaged in the clinical processG (Aleinman& 19!'& p.1'C & the concept generall. scrutini9es how patients interpret the cause and progress o- the illness and how the. thin> it should ;e treated. 75planator. models (73s are held ;. ;oth patients and practitioners& and the. pro1ide their perception o- ill-health ill in terms rms o-8 the cause o- the illnessK wh. it has occurredK what the condition does to the ;od. and the appropriate treatment (Hin>elman& 2''9 . ?he 73 approach recognises the importance o- patients< personal 1iews o- their health pro;lem in diagnosing as well as treating illnesses. )')' (llness causation Hhen conceptualising their 73s& patients usuall. ascri;e the aetiolog. o- their ill-health ill health to 1arious o;=ects or people. $n top o- the ;iomedical paradigm& which attri;utes the aetiolog. o- malad. to germs and or ;ioph.siological changes in the ;od. (Hin>elman& 2''9 K Helman (199' descri;es -our other theories o- illness causation& which ascri;e ill-health health to the -ollowing8 -irstl.& the indi1idual patient. )or instance& the indi1idual is ;lamed -or not ta>ing good care o- his2her diet& h.giene& smo>ing and others. Secondl.& ill-health ill is attri;uted to the natural worldK in particular& the en1ironmental -actors li>e climatic conditions (i.e. e5cessi1e cold . ?hirdl.& the aetiolog. is sometimes placed in the social social world. /lame here is put on sorcer.& witchcra-t and others. ?he supernatural world is not sparedK ill-health health can also ;e caused ;. direct actions o- supernatural entities li>e gods and spirits. )or instance& illness is seen as a di1ine punishment -or sin-ul sin-ul ;eha1iour. Helman noted that these theories are not mutuall. e5clusi1e ;ut he is silent on how the illnesses are speci-icall. ascri;ed to 1arious causes.

)igure 18 (onceptual -ramewor> showing that it is the 73 that determines the aetiolog. o- ill-health& ill which& in turn& dictate the appropriate t.pe (s o- care. ,' Methods ,'&' Setting of the stud% ?he -ieldwor> -or this stud. was conducted among 3ang<an=a ethnic group in (hi>hwawa& 3alawi. 3alawi is located in the southern part o- 4-rica. It is ;ordered ;ordered to the north ;. ?an9aniaK to the south ;. 3o9am;i@ueK and to the west ;. *am;ia. ?he countr. is di1ided into three regions (north& central and south which are -urther partitioned into 2! districts. It has the population o- around 1L million o- which which a;out !CJ sta. in the rural area (NS$& 2''!K ,HS& 2'1' . (hi>hwawa district is mainl. composed o- 3ang<an=a ("'J and Sena (#'J ethnic groups and it has one o- the worst maternal health indicators in 3alawi. 3ang<an=a as a group was chosen ;ecause it is the largest tri;e in the area. No speci-ic 1illages were chosen in the districtK the setting was simpl. de-ined ;. the presence or a;sence o- the concerned ethnic group mem;ers and not geographicall..

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,')' Stud% design In order to elicit e5planator. models -rom respondents& a @ualitati1e research design was pre-erred (,a1id and Sutton& 2'11 . Inter1iew guides& which were designed ;ased on 4rthur Aleinman<s 197! inter1iew guide& were de1eloped. ?he guides ;asicall. elicited three main themes a;out the maternal complications -rom the patient<s perspecti1e8 what causes it& how it a--ects them& and the possi;le treatment. 3ore speci-icall.& respondents were as>ed a;out their 1iews a;out haemorrhage which is the main cause o- maternal deaths in 3alawi and man. other de1eloping countries (Ieu;;el& 2''"K 0N 2'1'& 2'11 . In-depth inter1iews were the onl. tool that was used to collect data. ?he choice o- this tool was purel. on methodological grounds. )irstl.& ;. its nature& the Aleinman<s e5planator. model inter1iew guide -its well with in-depth Inter1iews. In addition& the aim o- the research was to elicit indi1idual e5planator. models and that automaticall. -its well with in-depth inter1iews& which are also good at drawing out an indi1idual perspecti1e o- an issue (/r.man& 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 ha1e at least one child. In particular& the respondents were ten pregnant women& ten old women& three traditional ;irth attendants and two traditional healers. ?he age range o- the respondents ranged -rom 1C to CC .ears. Participants were purpose-ull. recruited and inter1iewed in their 1illages. 4ll the inter1iews were done in the main local language ((hichewa . ,',' -ata management 4ll the inter1iews were transcri;ed and translated to 7nglish. ?he N1i1o @ualitati1e data anal.sis so-tware was used throughout the data anal.sis process. 4ll the transcripts were -irst trans-erred to N1i1o and read in great detail 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;stanti1e codes a;o1e (Punch& 199! . 4nal.tical acti1ities were conducted in a circular wa.& where;. tas>s were repeated& o1erlapped& or conducted simultaneousl. which ena;led deep penetration o- the data. ,'.' *thical considerations /e-ore -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. appro1ed ;. the National Health Science Research (ommittee (NHSR( as well as district and communit. authorities. In-ormed 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 gi1e to children and pregnanc.& ;eing pregnant is generall. seen as a dangerous status. 71en the two popular local names -or pregnanc. N Bpakati< (li-e or death and Bwodwala< (sic> woman N clearl. signal how pregnanc. is percei1ed as clari-ied ;. 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 relati1el. 1ulnera;le to ill-health. 4 .oung pregnant woman reasoned li>e this8 Dbecause the thing [foetus] inside me is e tracting 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 speci-icall.& respondents stated that B$uchepamaga%i< (anaemia & 3alaria& ;leeding& miscarriage& po1ert.& and 1iolence against women are the most serious maternit. pro;lems. 4lmost e1er. woman mentioned Bshortage o- ;lood< as a serious maternal pro;lem and 1arious causes were cited such as e5cess sunshine& malaria& poor diet& witchcra-t and o1erwor>ing. $ne woman said8 DWhen it is hot! our blood boils and evaporates &ust like boiling water.G 3ost women noted that shortage o- ;lood is 1er. 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 -e1er. 3os@uitoes& rain-all& o1erwor>ing and the pregnanc. itsel- are the ma=or causes o- 3alaria that were mentioned ;. the respondents. 3an. women also reported that 1iolence against them& o-ten 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 Dsome [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& di99iness& stomach-ache& swelling& pain-ul legs& nausea& 1omiting& ;lurred 1ision& -ainting& high ;lood pressure& witchcra-t and caesarean section. 4lthough man. women consider the pro;lems a;o1e 1er. 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 pregnanc. to the e5tent that some o- them are thought to ;e signs o- pregnanc.. Hhen as>ed how she disco1ered her

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pregnanc.& one woman said& DI stopped menstruating! I was e periencing nausea and vomiting! I suffered from (alaria and I was also feeling backache ....G .')' /ocal perception of ma or o"stetric pro"lem 0 1aemorrhage 4lthough haemorrhage is the leading cause o- maternal mortalit. in 3alawi (Ieu;;els& 2''" & 1er. -ew respondents 1oluntaril. mentioned it as one o- the maternal complications. Howe1er& this did not stop the researchers -rom pro;ing their perception or understanding o- the same. 4 closer loo> at haemorrhage -rom the participant<s perspecti1e re1ealed that there are two sides o- ;leeding during pregnanc. as well as postpartum. Hhile some respondents ;elie1ed that it is a health pro;lem& the ma=orit. loo> at it -rom another angle. $n one hand& ;leeding is seen as ser1ing important -unctions that help to sustain pregnanc.. /leeding during the earl. months o- pregnanc. is thought to ;e a ;loom that sweeps the menstruation le-to1ers -rom pre1ious months so as to create a good atmosphere -or the -oetus to de1elop. $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 womans uterus ....G 4part -rom that& ;leeding during pregnanc. is also seen as something which women inherit -rom their parents. Respondents argued that some women ha1e less sensiti1e ;odies which ta>e time to respond to pregnanc.K that is wh. the. continue menstruating8 Dsome women are &ust insensitive to pregnancy so they continue menstruating.G /leeding towards the end o- pregnanc. is percei1ed 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 smooth deli1er.. 4lthough the. -ailed to mention the speci-ic things which need to ;e cleared& ;ut the. insisted that the deli1er. passage needs to ;e cleaned ;e-orehand8 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 deli1er health. ;a;ies and one woman had a simple answer -or me8 Dyes! they dont 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 ser1es a -unction. Respondents generall. said that ;lood and all other wastes associated with the -oetus needs to ;e remo1ed -rom the ;od. a-ter deli1er.. 4ccording to the participants& i- these things are not cleaned& a woman ma. die ;ecause o- what the. called Bmtayo< (rotten stu-- associated with -oetus 8 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 ?here-ore& little ;leeding is seen as not ha1ing enough pressure to remo1e these le-to1ersK a local midwi-e said that Dwe e pect 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 who don<t ;leed enough a-ter deli1er.8 D... we insert a funnel in the vagina and water mi ed 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;ser1ed 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 unsa-e ;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 ;elie1e that ;leeding ser1es a -unction see it as a natural process& which needs neither e5planation nor treatment. Howe1er& 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. ?here-ore& 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 ;e used to -orm a -oetus. ?his is sometimes -ollowed ;. miscarriage. Secondl.& other respondents attri;uted it to witchcra-t. ?he. ;elie1ed 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 ;elie1e 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 se ual 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 percei1ed to ;e serious or that are regarded as normal during pregnanc. rarel. pro1o>ed a trip to an. care pro1ider. Home remedies or =ust a change o- ;eha1iour 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 1omiting and nausea& swollen& headache and di99iness ;ecause are not serious enough to warrant a care see>ing trip. $ne woman had this to sa.8 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 after childbirth.G Hhile 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 ;elie1e that haemorrhage is normal reported that the. did not see> an. speci-ic care when the. e5perienced it during their pre1ious pregnancies. Howe1er& -ew women mentioned that the. went to the hospital to get ;lood pills ;ecause the. were a-raid that the. would not ha1e enough ;lood to >eep their pregnanc.. $thers emplo.ed 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- ;eha1iour or li-est.le also emerged as a common therap. -or a num;er opro;lems. .',')' !raditional care 4ll respondents agreed that man. women use traditional medicine to treat or pre1ent 1arious maternit. pro;lems. 3an. women reported that the. 1isit the traditional healers to see> help when the. suspect that their pregnanc. was not sta;le. Se1eral women praised the traditional her;s as 1er. e--icient in pre1enting pregnanc. loss due to witchcra-t. $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 su--ering -rom a;dominal pain. ?his is to clear the menstruation le-to1ers& which are thought to ;e the cause o- a;dominal pro;lems during pregnanc.. Must li>e wastes need to ;e remo1ed a-ter deli1er.& so are wastes a-ter a miscarriage2a;ortion has occurred. ?raditional midwi1es reported that the. o--er cleaning ser1ices to women& which also include protection against -uture miscarriages. 4dditionall.& it was also reported that sometimes traditional help is sought as an alternati1e 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 pre1ious pregnancies. ?he superiorit.& relia;ilit. and e--ecti1eness o- the western medicine are some o- the reasons that attracted women to see> ;iomedical care. 3an. respondents o;ser1ed that it is onl. at the medical -acilities where high standard t.pe o- care is pro1ided. Some went as -ar as sa.ing that local healers and midwi1es >now nothing and that the. =ust want to earn a li1ing -rom cheating people8 D... these old women *local midwives+ are liars! they dont know how to treat problems but they still insist to help people. I cant 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].G 4lthough man. women said that the. see> care at the hospitalK most o- them do not >now wh. the. go there. Hhen as>ed wh. the. go to antenatal care& most pregnant women responded that the. =ust go there ;ecause the. are supposed toK no speci-ic clinical reasons were pro1ided. In -act& the. were all aware that the. need to 1isit the hospitalK ;ut -or them& the 1isits are =ust ha;itual. It was also noted that communities ha1e put in place penalties that are gi1en to women who do not see> medical care. ,uring the inter1iews& it was -re@uentl. reported that all women who -ail to see> medical care and conse@uentl. deli1er in their 1illages are lia;le to a penalt. in -orm oa goat or the e@ui1alent in cash. 2' -iscussion ?his discussion e5amines -our o- -i1e main @uestions that e5planator. models see> to e5plain8 course o- illness (i.e. se1erit. & aetiolog.& pathoph.siolog. and treatment (Aleinman& 19!' . 2'&' 3eneral perception of pregnanc%: normalit% of complications ?he stud. has re1ealed that pregnanc. is percei1ed in 1arious wa.s 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 li1es owomen. ?he names Bpakati< and Bwodwala< that pregnant women are >nown ;. spea> clearl. a;out their situation. ?his o;ser1ation 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;ser1ation ;ecause these pro;lems are at the same time regarded as li-e threatening. 4 closer loo> at this con-usion ;rings to mind Hin>elman<s (2''9 remar>s that illnesses are e5perienced and interpreted within a cultural conte5t& which de-ines the seriousness o- the condition. ?his ;asicall. implies that although the pregnanc. is generall. considered as a Bli-e or death< situation& at the same time the threats it poses has ;een culturall. internalised and normalised. Hith this normalisation& it should not ;e surprising that e1en when their li-e 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% evil It was also interesting to note that not e1er.one percei1es haemorrhage as a pro;lem. 3an. participants argued that ;leeding ser1es important -unctions in their ;odies. It is ;asicall. not >nown how these e5planations come a;out ;ecause e1en the respondents themsel1es were una;le to locate the source. Howe1er& it was clear that this >nowledge is culturall. accepta;le and it is passed on -rom one generation to another through ceremonies such as Bmwambowamimba<. It has ;een esta;lished that ;leeding is seen as pro1iding cleaning ser1ices to the uterus in the earl. months& and to the ;irth passage& in the last -ew wee>s o- pregnanc.. 4nd a-ter deli1er.& the -unction is to clear the wastes that the ;a;. le-t ;ehind in the uterus. In -act& little ;leeding is seen as unhealth. ;ecause it lac>s enough pressure necessar. to remo1e the dirt. Similarl.& (hiwu9ie and $>olocha (2''1 reported that 7>poma women in Nigeria go -urther to induce ;leeding a-ter deli1er. to ensure that their uterus is dul. cleaned. ?hese o;ser1ations di--er slightl. to what Hhite (2''2 -ound among the Ahmer women in (am;odia& who ;elie1e that ;leeding during pregnanc. ser1es to wash the -ace o- the ;a;.. Howe1er& the common perception o;leeding among Ahmer& 7>poma and 3ang<an=a is that the. all see it not as an o;stetrical pro;lem ;ut rather as ser1ing important -unctions necessar. to sustain pregnanc. and the li-e o- the woman. ?hese o;ser1ations are 1er. dangerous ;ecause the. can hinder timel. and appropriate care see>ing. 2',' Care seeking practices: Medical s%ncretism Hhile man. studies ha1e wor>ed on the assumption that ;iomedical is the onl. t.pe o- care a1aila;le to pregnant women ((urr.& 199'K Ilei& 2''2K 3.er O Harrison& 2''# & this stud. has re1ealed that at least three sources omaternal care are a1aila;le to women8 home remedies& traditional& and medical care. ?he most important o;ser1ation howe1er& is not these t.pes o- care ;ut rather how the. are chosen in times o- need. ?he -indings othis stud. con-irm 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 percei1ed. )or instance& illnesses which were regarded as normal or less se1ere to women rarel. pro1o>e a trip to an. healer. Respondents reported that illnesses li>e headache& ;lurred 1ision and swollen legs are normal in pregnanc. and indeed 1er. -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 se1erit. o- the illness is one o- the determining -actors -or care see>ing ;eha1iour ((ro.le& 2''C . Howe1er& unli>e H/3& it has ;een noted that it is not onl. the se1erit. 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 ;elie1es need no action as deli1er. itsel- is considered the ultimate treatment. It was -urther noticed that most people who ascri;ed the o;stetrical pro;lems to witchcra-t mentioned traditional care more o-ten than not as the appropriate treatment. 3ost o- them argued that hospital is irrele1ant to their pro;lems which were o-ten de-ined as either witchcra-t or ta;oo ;ased. ?his pro;a;l. stems -rom the ;elie- that ;iomedicine cannot success-ull. diagnose or treat illnesses emanating -rom witchcra-t as o;ser1ed ;. (hapman (2''# and (hiwu9ie O $>olocha (2''1 in 3o9am;i@ue and Nigeria respecti1el.. /ut what is not >nown is how the causes o- these illnesses are de-ined as witchcra-t ;ased or not. It is possi;le that some naturall. caused pro;lems are attri;uted to witchcra-t there;. dela.ing use o- appropriate care. 3ore research on this is recommended. 3an. women also reported recei1ing antenatal and child;irth care -rom the ;iomedical -acilities. Howe1er& what is clear a;out ;iomedical care is that women -ailed to =usti-. wh. the. sought the care or e1en to state the importance o- the ser1ices the. were gi1en. )urther e5ploration o- this issue re1ealed that not all women see> ;iomedical care 1oluntaril.K 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 re@uired. In general& although t.pes 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. ha1e con-irmed the e5istence omedical s.ncretism& the use o- di--erent >inds o- treatment at the same time (Pool O Ieissler& 2''! . 4' Conclusions Pre1ious studies ha1e documented that raising awareness o- women on the danger signs o- o;stetrical pro;lems is crucial -or the realisation o- sa-e motherhood and 3I,C (see Hhite& 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. Howe1er& e5planator. models elicited -rom 3ang<an=a people suggest that ;eing aware o- these danger signs is not enough to pro1o>e a trip to the appropriate healer. )or instance& some o- the danger signs are also considered part and parcel o- pregnanc. N normal. ?his stud. has there-ore& -ailed to -ind e1idence that >nowledge o- ris> -actors in-luence women<s decision to see> appropriate care. It has ;een o;ser1ed that the insider<s de-inition o- appropriate care is not -i5edK it is a -unction o- the de-inition o- the illness itsel-. )or instance& this stud. has showed that women<s >nowledge o- ;leeding as a dangerous

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complication did not automaticall. illicit a =ourne. to a medical -acilit.K most o- them reported utilising other modes o- healing. ?his stud. there-ore& has esta;lished that it is the percei1ed 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 percei1ed causes o- these complications are in turn a--ected ;. the traditional ;elie-s and practices surrounding the issue o- pregnanc.& child;irth and postpartum. ?he e5istence o- medical s.ncretism also implies that although each complication has a targeted healer& other practitioners are also consulted. Social& economic and political -actors such as transport cost& a1aila;ilit. o- -acilities and go1ernment policies also pla. an important role. 5' 6ecommendations In order to impro1e utilisation o- medical -acilities& a shi-t in approach o- health education pro1ided to women is recommended. Since it is the cause not the e--ect o- the complications that determines care see>ing& women need to ;e told the speci-ic causes o- these complications and the underl.ing ph.siological processes in a wa. the. can easil. understand in order to impro1e care see>ing. 4uthorities can also ta>e ad1antage o- the a1aila;le local structures li>e Bmwambowamimba< ceremon. to deli1er messages to women and communities. /ut ;e-ore such initiati1es are put in place& there is a need to understand how the local e5planations o- illness causation are de1eloped. 6eferences 4;im;ola& 4. (2'12 . (ultural -actors a--ecting pregnanc. outcome among the ogu spea>ing people o- ;adagr. area o- 6agos state& Nigeria. International .ournal of /umanities and 'ocial 'cience& 2 (L & 1##N1LL. 4dams& M.& O ?rinitapoli& M. (2''9 . ?he 3alawi Religion Pro=ect8 ,ata collection and selected anal.ses. 0emographic 1esearch& 23 (L & 2CCN2!!. 4rps& S. (2''9 . ?hreats to sa-e motherhood in Honduran 3is>ito communities8 local perceptions o- -actors that contri;ute to maternal mortalit.. 'ocial 'cience 4 (edicine! 56 (L & C79N!". 4t>inson& S.& O )arias& 3. (199C . Perceptions o- ris> during pregnanc. amongst ur;an women in northeast /ra9il. 'ocial 'cience 4 (edicine& 7(Ii & 1C77N1C!". /ernard& R.H. O R.an& H.R. (2'1' 8nalysing #ualitative data9 systematic approaches. (ali-ornia8 Sage Pu;lication. /r.man& 4. (2''1 . 'ocial research methods. New Por>8 $5-ord 0ni1ersit. Press. (hapman& R. R. (2''# . 7ndangering sa-e motherhood in 3o9am;i@ue8 prenatal care as pregnanc. ris>. 'ocial 'cience 4 (edicine! :;(2 & #CCN7L. (hiwu9ie& M.& O $>olocha& (. (2''1 . ?raditional ;elie- s.stems and maternal mortalit. in a semi-ur;an communit. in southern Nigeria. 8frican .ournal of 1eproductive /ealth& C(1 & 7C-!2. (ro.le& R. (2''C . Theory at a glance9 application to health promotion and health behavior. (2nd ed. . Hashington ,(8 National Institute o- Health (urr.& 3. 4. (199' . )actors associated with inade@uate prenatal care. .ournal of community health nursing& ;(L & 2LCNC2. ,a1id& 3. O Sutton& (. (2'11 'ocial research9 an introduction. (2nd ed. . 6ondon8 Sage Pu;lication. Ieu;;els& 7. (2''" B7pidemiolog. o- 3alawi.< (alawi (edical .ournal& 1!(L & 2'"-2C. Hailu& 3.& Ie;remariam& 4.& O 4lemseged& ). (2'11 . Anowledge a;out o;stetric danger signs among pregnant women in 4leta Hondo ,istrict& Sidama *one& Southern 7thiopia. <thiopian .ournal of /ealth! 2' (1 & 2C-#2. Hallen;ec> M& Ioldstein 3& 3e;ane 7. (199" . (ultural considerations o- death and d.ing in the 0nited States. =linics in >eriatrics& 12 (2 & #9#-L'". Helman& (. (199' =ulture! health and illness9 an introduction for health professionals. (2nd ed . 6ondon8 Hright. Hennin>& 3.& I. Hutter and 4. /aile.& (2'11 . ?ualitative research methods. 6ondon8 Sage Pu;lication. Aleinman& 4. (19!' . ,atients and healers in the conte t of culture9 an e ploration of the borderland between anthropology! medicine! and psychiatry. 6ondon8 0ni1ersit. o- (ali-ornia Press. Aleinman& 4.& 7isen;erg& 6.& O Iood& /. (197! . (ulture& illness& and care8 clinical lessons -rom anthropological and cross cultural research. 8nn Intern (ed& 2C1-!!. 6a9aro& ,.& O Namasusu& M. (2''C . @eed assessment of obstetric fistula in (alawi. *om;a8 Io1ernment print. 3alawi Human Rights (ommission (2''" =ultural ,ractices and their Impact on the <n&oyment of /uman 1ights! ,articularly the 1ights of Women and =hildren in (alawi. *om;a8 Io1ernment Print 3aternal and Neonatal Program Inde5 (2''C . (alawi9 1esults from the 2AA: 'urvey. (@,I. Retrie1ed Mune 2C& 2'12& -rom http822www.polic.pro=ect.com2pu;s23NPI23NPI2''C22''C3alawi.pd-

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3inistr. o- Health (2''C . 1oad (ap for 8ccelerating the 1eduction of (aternal and @ewborn (ortality and (orbidity in (alawi.< *om;a8 Io1ernment print. 3.er& 6.& O Harrison& 4. (2''# . Hh. do women see> antenatal care lateQ Perspecti1es -rom rural South 4-rica. .ournal of (idwifery 4 Womens /ealth& 7B(L & 2"!N272. National Statistical $--ice (2''' . (alawi 0emographic and /ealth 'urvey. *om;a8 Io1ernment print. National Statistical $--ice (2''! . ,opulation 4/ousing =ensus. *om;a8 Io1ernment print. National Statistical $--ice (2'1' . (alawi 0emographic and /ealth 'urvey. *om;a8 Io1ernment print $>olocha& (.& (hiwu9ie& M.& /raimoh& S.& 0nuig;e& M.& O $lume>o& P. (199! . Socio-cultural -actors in maternal mor;idit. and mortalit.8 a stud. o- a semi-ur;an communit. in southern Nigeria. .ournal of <pidemiology and =ommunity /ealth& :2(C & 29#N7. Pem;e& 4. /.& 0rassa& ,. P.& (arlstedt& 4.& 6indmar>& I.& N.strRm& 6.& O ,ar=& 7. (2''9 . Rural ?an9anian women<s awareness o- danger signs o- o;stetric complications. C(= pregnancy and childbirth& 6& 12. Pool& R& O Ieissler& H. (2''! . (edical anthropology. /er>shire8 $pen 0ni1ersit. Press. Punch& A. (199! Introduction to social research9 #ualitative and #uantitative approaches. 6ondon8 Sage Pu;lication. Sa-e 3otherhood Initiati1e (2''7 . 'afe (otherhood9 8 review *36B;-2AA:+. New Por>8 )amil. (are International Inc. 0nited Nations (2'1' . The (illennium 0evelopment >oals 1eport. New Por>8 0N. 0nited Nations (2'11 . The (illennium 0evelopment >oals 1eport. New Por>8 0N. Hhite& P.& 2''2. (rossing the ri1er8 Ahmer women<s perceptions o- pregnanc. and postpartum. .ournal of (idwifery 4 Womens /ealth& L7(L & 2#9N2L". Hin>elman& 3. (2''9 . =ulture and /ealth9 8pplying medical anthropology. San )rancisco8 Mohn Hile. and Sons. Horld Health $rganisation (2'12& 3a. . (aternal mortality9 fact sheet @o D7B. W/). Retrie1ed Mul.& #'& 2'12& -rom http822www.who.int2mediacentre2-actsheets2-s#L!2en2inde5.html

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