CASE STUDY:
Cultural Barriers to Reducing Maternal and Child Mortality: Insights from
Capricorn and Waterberg Districts in Limpopo
Developed By1
Intended Audience
Development Date
FAMSA, Limpopo and CHoiCe Trust
Department of Health, Maternal, Newborn, Child and Women’s Health
Directorate (MNCWH), Limpopo
Maternal, New-born, Child and Women’s Health Directorate (MNCWH)
December 2014
1. Introduction
South Africa will not be achieving the Millennium Development Goal 4 target of an under 5 mortality
rate of 20 per 1,000 live births by 20152. In Limpopo Province, the 5 highest causes of deaths in
children under 5 (as pictured below) account for more than 70% of deaths in children.
3
Child survival indicators-South Africa and
Limpopo
Death due to severe malnutrition in
under 5 yrs
56.30%
64%
78%
84.20%
Immunization coverage
ANC attendance
85%
88%
Delivery in health facility
86%
89%
Exclusive brestfeeding up to 6 months
Limpopo
South Africa
8%
Mix feeding under 6 months
53%
0%
20%
40%
60%
80%
100%
Taking note of the poor performance towards achieving the MDGs, the African Union Commission
initiated the Campaign on Accelerated Reduction of Maternal and Child Mortality (CARMMA) which
aims to promote and advocate for renewed and intensified implementation of the Maputo Plan of
Action for Reduction of Maternal Mortality in Africa. In spite of innovative and aggressive efforts to
reduce infant and child mortality, culture continues to impact on the achievement of positive health
1
This document was developed with the support of the Department of Health, Limpopo Province and the
stakeholders who shared their time and experiences during the consultations. The Okuhlekodwa Research and
Development Consultants was used to serve as a learning officer and document the process and tools.
2
Health Systems Trust (2013)
3
HST (2010); Department of Health, Medical Research Council & ORC Macro (2007); HSRC (2010)
outcomes. Negative cultural beliefs, attitudes and practices are barriers to accessing health
information and services, including maternal and child health services.
2. The Intervention
In order to interrogate and unpack the role of culture and traditional practices in the demand for and
uptake of mother and child services, RMCH supported FAMSA and CHoiCe Trust in the facilitation of
community consultations with relevant stakeholders from July to November 2014. Four consultations
took place in each of Waterberg and Capricorn Districts in Limpopo Province, engaging groups of (i)
men; (ii) women; (iii) health practitioners from public health; and (iv) traditional health practitioners
(THP). Ten stakeholders from within each group came together for a multi-stakeholder consultation in
Waterberg to further interrogate the findings of the individual consultations and identify an Action Plan
and way forward.
The consultations adopted a dialogue methodology based on the Partnership Defined Quality (PDQ)
model4 to explore different perspectives on harmful cultural practices with regards to maternal and
child health. The purpose of this methodology was to create a space of open sharing in which
participants could prioritise the key challenges they faced and how they could address the root
causes of these issues. The outcomes of these consultations was (1) findings on harmful cultural
practices which impact on maternal and child health; and (2) recommendations on how to address the
issue, incorporating activities in a Work Plan developed by the participants following the consultations.
3. Findings
Participants had a broad understanding of mother and child health, which included reproductive
health and family planning; pregnancy; birth of a child; and the first years of the child’s life, including
all aspects along the continuum of care.
3.1 Family Planning and Reproductive Health
Traditional family planning methods are believed to be safe and do not involve use of medicines, but
rather specific actions. One form of traditional contraception is the burying of used sanitary towels
during menstruation (mixed with ashes and herbs/muti). Youth showed an understanding of the
importance of using medical contraceptives, and were therefore more likely to ascribe to dual
methods of birth control (i.e. burying used sanitary pads and making use of family planning services
from a health facility).
There is a general feeling that people should go to clinics for family planning services, although
teenagers do not make use of this service effectively. Reasons for this include that they do not wish
to go to the clinic due to negative attitudes of nurses at the clinics, that there is insufficient advice and
support from parents, and that there may be pressure for teenage girls to bear children to ‘please their
boyfriends’.
3.2 ANC
Many women explained that they were fearful when pregnant; some lacked information on what to
expect; some felt they had disappointed their families in being pregnant young or while at school;
some feared being bewitched; and some thought of others who had lost children in birth.
4
This model was developed by Save the Children (Lovich, R., Rubardt, M., and Powers, M.B., 2005). The
methodology seeks to engage and link the supply side with the demand side through individual and multistakeholder consultations.
There is a general consensus amongst community members, health practitioners and traditional
health practitioners that ANC should take place at a health facility and that women should register at
the facility as soon as they find out that they are pregnant. Health facilities are recognised for their
role in identifying and addressing any abnormalities with the process and protecting the health of the
mother and child; THP, on the other hand, are viewed as pivotal in protecting the mother and child
from harm and evil spirits through the use of traditional methods and practices. This includes, for
example, the tying of a rope around the abdomen of a pregnant women which is only untied when she
is ready to give birth. THPs feel that the health of mothers and babies could be improved if health
practitioners recognised the role of culture and encouraged mothers to respect and conform to diila
(customs). In order to avoid judgment by health professionals for pregnant women who make use of
traditional medicines, THP advise mothers not to disclose what cultural medicines they are making
use of during their pregnancy.
The health professionals highlighted that late presentation for ANC may be a result of a belief that a
woman’s pregnant state should be concealed and this is not necessarily being emphasised by the
THP, although a greater role could be played by the THP in ensuring immediate enrolment in ANC
and open discussion of what cultural treatment has already been initiated. However, health
practitioner’s attitudes towards patients that do make use of traditional treatment would have to
change in order to provide an environment that is conducive for such disclosure, absent of negative
reactions.
3.3 Birth
THPs believe caesareans are high risk and can be avoided through the use of traditional medicines to
facilitate natural birth. The THPs believe that the health of the mother and baby are compromised by
the absence of recognition by health practitioners for traditional medicines which the mother may be
using at the time of the birth.
When discussing their experiences with birth, the health professionals generally had negative and
extreme stories concerning birth – ranging from experiencing someone giving birth at the gate of the
clinic to being splattered with blood. One health professional shared that while still a 3rd year student,
she assisted a woman who was in labour and got splattered by the woman’s blood. That experience
made her hate being a midwife. In these recollections the health professionals illustrated a sense of
fear, frustration and aversion to the process of birth, some even admitting that they are doing this for
the money.
3.4 Post-Birth and Child Health
From the consultations it emerged that THP and traditional practices are most frequently utilised after
the birth of the baby, most particularly those THP who ‘specialise’ in these areas around maternal and
child health. The THP themselves were aware that there were persons amongst them who were
‘bogus’ and who would accept payment for services around the mother or the new-born which they
could not actually perform. THP are reportedly the authorities in the treatment of childhood illnesses
such as hlogwana (the curving in the soft spot on the infant’s head) and lekone or tema (the read
mark at the back of the infant’s neck), and the THP shared that even health professionals personally
make use of their services in this regard. Both conditions are believed to be of cultural significance
and can thus only be treated with cultural medicines and practices, including the cutting of the infant’s
neck with a razor blade and the rubbing in of traditional medicine.
During the consultations it further emerged that many traditional post-birth practices involve the
mother rather than the new-born child. Although the mother is also required to undergo a traditional
cleansing of the womb, she should also take further steps to ensure the health of her baby, including
that she may not have sexual intercourse for a certain period after the birth, that she is expected to
confine herself and her baby from others, and that her clitoris may be cut and her blood mixed with
traditional medicine and that of her child in order to be given back to the mother and the child in the
treatment of lekone.
A prescribed traditional practice that has negative implications for the health of a child (considering
the importance of exclusive breastfeeding for 6 months) is mothers being discouraged from feeding
from an engorged breast, which is believed to have been contaminated by the baby through “burping”
on the breast. Very often, women are advised to stop breastfeeding completely once this has
occurred.
3.5 Use of Health Services
During the consultations, participants shared on the different factors which attracted them to the
different points of service that they would make use of with regard to issues around maternal and
child health.
Service Point
Clinics, hospitals
and mobile units
Pull Factors
Services are free
Pregnant women are able to get care
A wide variety of services are provided (such
as counselling and testing, and blood
pressure check-ups)
Health professionals are skilled and informed
Information (such as health talks) are given
Medical equipment and supplies are available
for babies (such as immunisations and
incubators)
Traditional health
practitioners
These are easily accessible
No ambulance or travel is needed
The care given from these points are good
and they are trusted
THP are turned to for guidance and advice
Treatment is always available
The THP give protection against evil spirits
Private health
services (including
doctors and
pharmacies)
Chemists and surgeries are private and
people will not know what service is being
used (confidentiality)
There is no compulsory HIV testing
There is also an explanation on how to use
the medication and treatment that is provided
There is a status associated with making use
of private services or medications
These are easily accessible and good care is
given
Prophets can provide protection against
miscarriage and evil spirits
Prophets and
religious healers
Push Factors
Shortage of staff
Long queues
Shortage of treatment, such as
immunisations
Travel distances to clinics or facilities
Delays in transportation / ambulances
Bad attitudes of health professionals and
lack of communication at clinics
Clinics being cold
Fear from mothers about the pain of
stitches or other procedures
Unreliability of mobile clinic services
Some of the practices are recognised as
being potentially harmful (such as use of
unmeasured quantities of herbs; use of
dung on umbilical cords; cutting of
children; giving a baby smoke or
traditional alcohol)
Some THPs accept payment for areas in
which they are not specialists and not
equipped to treat
Higher cost (profit-driven)
Less accessible
Lack of longer-term support or monitoring
of progress
Lack of follow-up or control on use of
self-prescribed medication
There is no medication or health support
3.6 Male Perspectives
When asked about maternal and child health, men tended to agree that clinics and health facilities
were the most reliable resources with regards to ANC, birth and after the birth. Older men were more
likely to recognise the role of the THP and churches, although they expressed concern over practices
during the birth and referenced more clearly post-birth interventions as being useful. Men, however,
particularly the older men, tended to be wary of family planning services offered by clinics due to
beliefs that this affected their own performance and virility.
The consultations with men illustrated that they did have an understanding of many of the aspects
and barriers to maternal and child health. Many commented that they recognised that they had a role
to play and wished to be involved in supporting their pregnant partners; some commented that the
health system itself prevented them from being able to be part of the process as they were not
permitted in the clinics during times such as attending the child birth.
4. Recommendations
The following recommendations were extracted from the findings as well as from the way forward
identified by the participants in the consultations who developed an Action Plan as part of the
process.
a. Engagements between THP and Health Professionals – From the consultations it was clear
that the THP were referring pregnant women for ANC and recognised the importance of the
health interventions at the clinic. The platform for further engagements between the medical
health practitioners and traditional health practitioners to strengthen these referrals and
address traditional practices which are still potentially harmful to the health of the mother and
the child could be effective. If the THP feel that their role is respected, they can ensure that
the health professionals supporting the pregnant women and new-born child have all the
information necessary to provide effective health care, including whether cultural medicines
have been taken or not. An understanding and acceptance of each’s role within the
continuum of care and agreements about what practices are helpful and which are advised
against would further support the women seeking treatment as they would not choose the
THP over clinic services and therefore never reach the clinic; even if they are also accessing
the THP for additional support, they would also be advised to go to the clinic.
“If we as health workers and traditional healers sit together and come up with better ways to
assist the community we can fight the high death rate.”
b. The role of religious leaders and prophets needs further discussion – Many women discuss
the role of prophets and spiritual blessings as part of the services they seek when pregnant,
which illustrates the importance of spiritual health and wellbeing during this period. Some
prophets have been known to give muti to pregnant mothers and new-borns, but even others
who are not providing treatments are approached for emotional and spiritual support. These
actors could have a role to play in the referral networks to ensure that pregnant women are
advised appropriately with regards to ANC and post-birth care.
c.
The role of men in maternal and child health could be strengthened – Although in many
instances this may require behavioural change amongst men who do not currently view
themselves as having a role in the health of the mother and child, there are men who wish to
get involved but are not able to. By considering the manner in which the health system is
accessible to pregnant women and their partners (such as during ANC visits or during the
birth), men can be welcomed into the process and given a responsibility in supporting their
partners through the healthy births of their children and the post-birth care.
d. Improved access to clinics – Based on the consultations, there were various factors which
pulled clients towards the clinics, and factors which prevented clients from using these
services consistently. The factors which attract people should be considered for the
identification of ways to further enhance these, while the factors which prevent use could be
addressed where possible to improve uptake of clinic services.
e. Further community awareness is still needed – While some participants mentioned
campaigns, and others specified the availability of IEC materials at clinics, the importance of
giving community members an understanding of the factors affecting mother and child health
is clear. This particularly includes pre-pregnancy so that the woman recognises as soon as
possible that she is pregnant and is immediately able to access these services.
This project was implemented by CHoiCe Trust in partnership with FAMSA, Limpopo and with the
support of the Reducing Maternal and Child Mortality through Strengthening Primary Health Care in
South Africa (RMCH) Programme. The RMCH programme is implemented by GRM Futures Group in
partnership with Health Systems Trust, Save the Children South Africa and Social Development Direct,
with funding from the UK Government. www.rmchsa.org
ANNEXURE A: SOME TRADITIONAL PRACTICES
Practice
Burying of used sanitary towels mixed
with muti
Herbs ingested by a woman (sekanama)
Tying of the rope around the belly of a
woman (motlamo)
Tying of the rope around the belly of a
pregnant woman (motlamo)
Placement of animal dung on the
umbilical cord of the infant
Child is given necklace with cheetah
teeth
Child is given tea when sick
Giving the child herbal remedies
(mehato; serokolo; etc)
Bathing a child in herbs
Not touching a baby after a funeral
A male must not engage in sexual
intercourse with different partners while
the baby is still young
The mother must not engage in sexual
intercourse
Feeding a baby traditional alcohol
The mother may not breastfeed the
baby while pregnant with another
Sunlight placed on the anus of the baby
Insertion of herbs into the anus of a child
(nogana ya mathosa)
Cutting of a woman’s clitoris
Carrying of a stone on a pregnant
woman’s back (makgorometja)
Drinking of an ostrich egg shell
Drinking of a LP record concoction
Cleansing of the woman after birth
The throwing of a rock by the woman
Discarding breast milk after a funeral
Women are prevented from eating
certain foods during pregnancy
Meaning
It is believed that this is a form of birth control and must be done by a THP or
elderly woman. In order to get pregnant, the ashes need to be removed from
the ground. If the THP or elderly woman has died or removed from the area,
it is believed the woman may never fall pregnant.
Prescribed by the THP to terminate pregnancies
To be conducted by a THP, it is believed that the rope will assist to prevent
the woman getting pregnant
To be conducted by a THP, it is believed that this will protect the pregnancy
and prevent the woman from giving birth too early (she will only give birth
after the rope is cut by the THP).
This is the way that THPs treat the umbilical cord after birth. Others report on
the placement of battery powder instead
It is believed to assist with teething. For one, it soothes the gums when
children chew on it, and it is also believed to ensure that teeth come out in the
correct order, namely the lower incisors first. It is believed that if the upper
incisors show first, the child can either possess evil spirits or thus be a danger
to others, or the child could possess supernatural positive powers which will
bring luck to himself/herself and those around him/her.
The THPs and prophets may prescribe a tea for illness
This can be used to prevent evil spirits and diseases, including flu
The THPs may bathe a child in herbs to prevent evil spirits from entering the
child
It is believed that evil spirits can be passed on to the baby after a funeral and
persons in attendance must not make physical contact with the baby
This can cause the baby to get sick and the male may lose his sexuality
It will pollute the child that is breastfeeding, which will lead to illness
This can be used by THP as part of treatment
It is believed that the baby that is born will be affected (it may have a large
head and very thin legs)
This is believed to assist a constipated child to defecate
The insertion of the herbs by the THP is believed to cure the child of worms
This can be done by THP to reduce a woman’s sexual drive as a means of
birth control
A THP gives a woman a stone to carry on her back from her home to
wherever she is delivering her baby. It is believed that the baby will only be
born after she has done this
After boiling the shell, the woman must drink the water in order to initiate the
labour
An LP record is boiled in water and the woman must drink the water in order
to hasten the birth process
There are different ways for this to be carried out, including with the use of
muti, so that the woman is able to be cleaned before being seen by others
after giving birth
In order to combat post-labour pains, the woman must carry a rock on her
head and her new-born baby on her back every morning for 3 days. She
must walk a distance as instructed by her maternal grandmother and must
then throw the stone without looking in the direction that she throws it
It is believed that the breast milk may carry evil spirits and a lactating woman
must discard this milk before feeding her baby
It is believed that certain foods will negatively impact on the baby. This
includes eggs (especially yolks) and oranges.