Childbearing in Malawi, Africa
1998; Elsevier BV; Volume: 27; Issue: 2 Linguagem: Inglês
10.1111/j.1552-6909.1998.tb02610.x
ISSN1552-6909
AutoresSusan Gennaro, Lennie Adeline Kamwendo, Ellen Mbweza, Rose Kershbaumer,
Tópico(s)Global Maternal and Child Health
ResumoMalawi is a small, landlocked country in South Eastern Africa that faces many challenges in providing health care to childbearing women. Through a partnership between the faculty of the University of Pennsylvania, School of Nursing, faculty of the Kamuzu College of Nursing in Malawi, and the Malawi Ministry of Health and Population, an ongoing collaboration has led to research and demonstration projects designed to improve the health of women and children in Malawi. To underscore the cultural context within which childbearing occurs, care of the childbearing family in Malawi is described, as is research that has documented some of the similarities and differences between childbearing in Malawi and the United States. Malawi is a small, landlocked country in South Eastern Africa that faces many challenges in providing health care to childbearing women. Through a partnership between the faculty of the University of Pennsylvania, School of Nursing, faculty of the Kamuzu College of Nursing in Malawi, and the Malawi Ministry of Health and Population, an ongoing collaboration has led to research and demonstration projects designed to improve the health of women and children in Malawi. To underscore the cultural context within which childbearing occurs, care of the childbearing family in Malawi is described, as is research that has documented some of the similarities and differences between childbearing in Malawi and the United States. Health care for women and children, with specific attention to the reduction of maternal mortality and morbidity, is the focus of a partnership between faculty from two university schools of nursing, one in Malawi and one in Pennsylvania, and the Malawi Ministry of Health and Population. As part of this partnership, beliefs and practices of childbearing women in Malawi have been identified. Sensitivity to cultural beliefs and practices is central to the development of health care delivery systems that are acceptable to the patients they are designed to serve. Thus, knowledge of some of the cultural practices and their meaning in Malawi are not only helpful to clinicians in that country, but also provide all clinicians with an understanding of the importance of the cultural context within which health care is provided. Cultural sensitivity is especially important when caring for childbearing women because cultural traditions are fundamental to the way women choose to birth their infants.There are many similarities and great differences between childbearing in Malawi and the United States. In both countries, pregnancy-induced hypertension, premature labor and delivery, premature rupture of membranes, and ectopic pregnancies are prevalent health problems. The most common problem faced by neonates in both countries is preterm birth. In both countries, childbearing women and neonates are regarded as unique beings with physical, psychologic, social, and spiritual needs who need individualized and comprehensive care, and nurses use the nursing process to assess and intervene to provide optimal care. Health manpower shortages in Malawi have parallels to shortages in some parts of the United States, where geographic and economic barriers limit access to care. To maximize health manpower, all nurses in Malawi also are educated as nurse-midwives.Economic and Geographic BackgroundMalawi is a small, landlocked, developing country in South Eastern Africa, bordered to the north and northeast by the United Republic of Tanzania, to the east, south, and southwest by the People’s Republic of Mozambique, and to the west by the Republic of Zambia. The predominant vegetation is the savanna woodland, with evergreen forests in places where water is plentiful and grasslands located in high plateaus. Malawi is a former British protectorate; it became independent in 1964 and has a democratic government under the leadership of President Bakili Muluzi. The official languages of Malawi are English and Chichewa.The economy of Malawi is based on agriculture, with 90% of the population living in rural areas, and agriculture accounting for 90% of export revenues. The principal export crop ofMalawi is tobacco, but tobacco is not processed in the country, so cigarette smoking is not common, and the health problems associated with tobacco use are not commonly seen. Other important agricultural groups are maize (corn), tea, sugar cane, groundnuts, cotton, wheat, coffee, and rice.Health Care Delivery in MalawiThe United States and Malawi have great differences in the health care delivery system because of the wide economic gap that exists between the two countries. Health care in Malawi is nationalized, and the government, under the direction of the Ministry of Health, runs hospitals and district health centers throughout the country. Roads are well established in the major cities. However, the transportation infrastructure in the rural areas, home to most of the population, is hindered by inadequate all-weather roads. In addition, many villages have no roads that are accessible to vehicle transportation. This results in unequal access to health care.Malawi has a national maternal mortality of 620 per 100,000 live births, and childhood mortality is 234 per 1,000 live births (Demographic and Health Survey, 1994Demographic and Health Survey Malawi demographic and health survey, 1992. National Statistics Office, Zomba, Malawi1994Google Scholar). The high childhood and maternal mortalities are a reflection of the socioeconomic constraints experienced by Malawi in the provision of health care to women and children.Malawi has a national maternal mortality of 620 per 100,000 live births, and childhood mortality is 234 per 1,000 live births. The high childhood and maternal mortalities are a reflection of the socioeconomic constraints experienced by Malawi in the provision of health care to women and children.Reported death rates in Malawi are generated from hospital reported deaths, and because so many women give birth at home in the villages, maternal mortality is under reported. To improve health outcomes the government has been involved in providing training to traditional birth attendants (TBAs), who usually are elderly women who attend mothers during labor in rural settings. These TBAs are given a 2-week training course consisting of theory and practice on simple and safe midwifery practices and are taught how to provide hygienic deliveries and to promote health education to mothers. Another strategy designed to improve access to health care is the establishment of maternal waiting houses, where women who live too far to travel to a hospital can wait for labor to begin. Another provider of health care in Malawi is the Christian Hospital Association of Malawi’s hospitals and health centers, which are run by church affiliated organizations.Malawi has a population of 10 million (Demographic and Health Survey, 1994Demographic and Health Survey Malawi demographic and health survey, 1992. National Statistics Office, Zomba, Malawi1994Google Scholar), with 52% of the population being female. Despite women being numerically in the majority, their social status is low in some respects, including their ability to be primary decision makers in terms of reproductive health. Although family size and timing of pregnancy are largely decided by the father of the family, some evidence suggests that women play a role in deciding their family size. Large families are favored in Malawi. For example, the Demographic and Health Survey, 1994Demographic and Health Survey Malawi demographic and health survey, 1992. National Statistics Office, Zomba, Malawi1994Google Scholar shows that 44.6% of women with two living children considered having five or six children or more as ideal; 43.7% of men considered that number ideal. The current fertility rate is 6.7% (Demographic and Health Survey, 1994Demographic and Health Survey Malawi demographic and health survey, 1992. National Statistics Office, Zomba, Malawi1994Google Scholar).Although women’s decision making may be secondary to that of their partners in terms of when pregnancy should occur and how often, once pregnancy is confirmed, the event becomes controlled by women. According to the National Safe Motherhood Task Force of Malawi, 1995National Safe Motherhood Task Force of Malawi Making motherhood safe for Malawian women. Ministry of Health, Llongwe, Malawi1995Google Scholar, 44% of all births in Malawi occur at home, either with the help of TBAs or other female relatives. Of the births that occur in the hospital, most are conducted by midwives, most of whom are female.In one study of 396 pregnant women who attended antenatal clinics in a rural area of Mangochi district, less than 25% of the women delivered in the health center (Lule and Ssembatya, 1996Lule, G., & Ssembatya, M. (1996). Intention to delivery and delivery outcome: The female client and health care. Available online: http://www.idrc.ca/books/focus/773/lule.html.Google Scholar). More than 50% of the primigravida women in the study and 40% of the nonprimigravida women reported that their husbands had instructed them to attend the clinic. Most (86%) women walked to the health center for antenatal care, whereas the remaining 14% were carried to the health center by their husbands on bicycles. The mothers spent a mean time of 7.7 hours (standard deviation, ± 4.3 hours) traveling from home to the health center and back. Of mothers who delivered at home, most (53%) said that by the time they realized they were in labor, they could not make it to the health center or to the nearest trained TBA’s place in time. Twenty-one percent of respondents said that they delivered at home because their own experience or that of others showed that certain midwives were unkind to mothers during labor. Another 10% mentioned that an older female relative had refused to let them go to a health institution or to a TBA’s place when in labor.Similarities Between Childbearing Education and Family Centered CareIn both the United States and Malawi childbirth education is an important component of nursing care, especially at prenatal visits and during the postpartum period. The content is similar to that given to clients in the United States. However, childbirth education programs in Malawi exclude women’s partners or spouses, and there is less focus on orientation to delivery suites and pain relief measures. Because most women in Malawi are illiterate, teaching methods include drama, songs, and pictorial illustrations for teaching aids, as compared with the United States, where teaching manuals, handouts, and pamphlets are used.In both the United States and Malawi childbirth education is an important component of nursing care. Although content is almost similar to that given to clients in the United States, most women in Malawi are illiterate, so teaching methods include drama, songs, and pictorial illustrations.Family centered care is central to childbearing in both the United States and Malawi. Families provide social support and assistance in decisions concerning care. In the United States it is common to have the father of the neonate actively participating in the mother’s labor and in the infant’s birth. Husband attendance during labor and delivery rarely occurs in Malawian settings because of cultural norms and taboos. However, it is common to see mothers, aunts, and mothers-in-law providing support. The presence of the family during labor is rarely allowed in most labor wards in Malawi because of inadequate space and privacy. Members of the family wait outside the labor ward and are informed of progress. In both countries, time is allowed for families to visit their relatives in postnatal wards and neonatal units to encourage family centered care. The needs of the family are considered when planning care during prenatal, labor and delivery, and postnatal and neonatal periods in both countries, and in both countries social workers are involved when there are family problems.Malawi is divided into 24 districts, and people from each district have different cultural beliefs and practices related to childbearing and child rearing. Some of these practices, such as the request for the placenta after delivery so that the placenta can be disposed of properly, also are seen among some groups of women in the United States. Other cultural variants that can be found in both countries are cultural beliefs regarding who should be allowed to pick up newborns. In Malawi, infants are handled only by married people or those who have not engaged in extramarital sexual relationships so as to prevent protein-energy malnutrition locally known as “Tsempho.” In the United States, especially in the rural South, cultural taboos exist that forbid menstruating women from picking up newborn infants.Differences Between Childbearing in the United States and MalawiAs is true in every country, there are many culture-specific beliefs and practices that surround childbirth in Malawi. Generally, either an aunt or the woman’s grandmother serves as a guide for the pregnancy. If the woman has any risk of abortion, she is given either a concoction made from kabata leaves (black jack or Bidens pilosa) to drink or a string made of ropes taken from a medicinal plant to wear around her waist (Kamwendo, 1996Kamwendo L.A. Birth rituals: The Malawian perspective.in: Conference Proceedings, ICM 24th Triennial Congress. International Congress of Nurse Midwives, Oslo, Norway1996: 135-138Google Scholar, p. 135). This string must be removed from the waist as soon as labor starts because continued use of the string is thought to prolong or obstruct labor.Near the end of pregnancy, a group of elderly women representing the woman’s family and that of her husband hold a private session with the pregnant woman in which advice is given on cessation of sexual relations starting in the seventh month of pregnancy because it is thought intercourse beyond this period would result in the infant being born with excess vernix caseosa (E. Simbeye, personal communication, March 1995). Preparation of clothes for the infant is discouraged because this is believed to result in the neonate being stillborn. From about the eighth month of pregnancy, either the woman’s mother or mother-in-law stays in the expectant family’s home to help the woman with household chores.Once the pregnant woman goes into labor she is advised not to cry but to bear the pain of uterine contractions silently. If she cries, she is considered a disgrace, not only to her family, but also to her cultural group. To prevent prolonged labor, the woman is advised to avoid standing in doorways or peeping through windows. It is believed that these actions lead to the fetus being stuck in the pelvis. Women in labor are given a porridge mixed with chibwaka (sweet potato leaves or Ipomea batatas leaves) or raw egg. These substances are thought to have oxytocic properties, and experience has shown that women who admit to having taken this local oxytocic do have short first and second stages of labor (Kamwendo, 1996Kamwendo L.A. Birth rituals: The Malawian perspective.in: Conference Proceedings, ICM 24th Triennial Congress. International Congress of Nurse Midwives, Oslo, Norway1996: 135-138Google Scholar). Prolonged labor is to be avoided because it usually is attributed to infidelity either by the woman or her husband. During the second stage, perineal tears are prevented by using the squatting position. Alternatively, the woman sits on a ring made of grass.Burying the placenta with the maternal side facing downward is thought to prevent secondary sterility (E. Kamungu, personal communication, April 13, 1995). Some families prefer to throw the placenta in a deep pit so that no one will be able to retrieve it. The woman is considered to be “dirty” for as long as she is discharging lochia or for a period of 1 to 2 months after delivery. Because of this, she is not supposed to sit on a chair or share the same bed and eating utensils with her husband. She is not allowed to cook for fear of contaminating her husband. Sexual intercourse is prohibited for at least 6 months. Once menses resume, the woman is considered to be clean, and she must donate the clothes she wore while unclean to her grandmother or to an aunt (Kamwendo, 1996Kamwendo L.A. Birth rituals: The Malawian perspective.in: Conference Proceedings, ICM 24th Triennial Congress. International Congress of Nurse Midwives, Oslo, Norway1996: 135-138Google Scholar). These practices differ among different cultural groupings in Malawi. However, the variations tend to exist in the mode of practice, rather than in the basis for their institution.In terms of newborn care, the infant is kept indoors until the umbilical cord falls off and is not named until this time. When the cord falls off, the infant is bathed in cold water to which medicinal herbs have been added. The umbilicus is treated with ashes obtained either from burning maize cobs or pumpkin vegetable flowers.Although these cultural practices underscore some differences between childbearing in Malawi and in the United States, they also highlight the prevalence of unwritten, but well accepted, cultural prescriptions that women are encouraged to follow to have a successful childbirth outcome and a healthy newborn. The prescription against standing in doorways in Malawi is similar to the ban in the United States against raising one’s arms above one’s head during the last trimester of pregnancy. Although neither action results in stillbirth, these bans and the advice against preparing clothes for the infant seen in both cultures underlines the ancient concern that all women share: that their infant be healthy and that they do everything possible to ensure that health. Naming customs are common in many cultures, as are prescriptions regarding the care of the infant during the neonatal period.Clinicians need to understand the cultural beliefs that are supposed to improve pregnancy outcomes so that they can provide care that is acceptable and useful to their clients. For clinicians caring for women who have had a poor pregnancy outcome, it is important to understand beliefs that might encourage a woman to unrealistically feel that her actions contributed to that outcome.Cultural traditions also can be used by nurses to achieve desired health outcomes, so it is helpful to understand cultural traditions surrounding nutrition, rest, and the resumption of sexual activity. Caregivers also need to be able to identify cultural traditions that do not help or empower women but may instead benefit the caregiver. The ban against crying out during labor in Malawi is also seen in the United States. In both cultures, positive reinforcement is given to women who are stoic during labor, but reinforcing this tradition may establish standards of behavior that are not helpful to the laboring woman.PENN-Malawi Women for Women’s ProgramFor the past 7 years as part of the PENN-Malawi Women for Women’s Health program, faculty of the University of Pennsylvania have been in partnership with faculty from the Kamuzu College of Nursing in Malawi and with the Ministry of Health and Population to increase our knowledge base, through research, as we all strive to improve the health behaviors and outcomes of Malawi mothers and children.As part of this project in 1996, 15 villages were selected randomly using the sealed envelope technique from all of the villages in the Chimutu Traditional Authority. Nurse data collectors visited these villages and interviewed all childbearing women and their partners who were available and willing to be interviewed on the day of their visit. A total of 189 men and women were interviewed in the selected villages. The interview schedule was developed by researchers from Malawi and the United States and was pilot tested and changed based on the responses of a number of church women in Malawi to ensure that the questionnaire was valid. The questionnaire was translated into Chichawa and back translated into English to guarantee appropriate translation.The findings from this project are being used to evaluate the efficacy of an educational intervention designed to empower women to make safe choices during the childbearing process. Some of these findings are shared here to illustrate the importance of the cultural context within which health care is delivered.In both the United States and Malawi many women do not receive adequate prenatal care. In Malawi, almost all respondents felt that receiving prenatal care was important (99.5%), and 88% of the respondents said that they or their wife received prenatal care with their last pregnancy. For 34% of the respondents, prenatal care started after the sixth month of pregnancy, but 58% of respondents reported that prenatal care began during the first four months of pregnancy.However, only 62.4% of the Malawi sample said that receiving postpartum care was important. A typical comment regarding postpartum care was “the baby is already born so what is the point?” When asked if they received postpartum care in their last pregnancy, 53% (100) of the respondents said no. This is congruent with national Malawian statistics, in which only 25% of 600 women who were surveyed reported that they received postpartum care (National Safe Motherhood Task Force of Malawi, 1995National Safe Motherhood Task Force of Malawi Making motherhood safe for Malawian women. Ministry of Health, Llongwe, Malawi1995Google Scholar).Substance use, such as cocaine and heroin, is not a problem in Malawi, as it is in the United States, but in both cultures nonprescribed medications are used in a belief that they will hasten the onset and duration of labor. Among the Malawi sample, most respondents did not believe that herbal medicines were as safe as prescribed medicines (79.9%), although some respondents (18.8%) believed that herbal medicines were safe. Surprisingly, although most respondents did not think taking herbal medicines was safe, a large number of women reported using herbal medicines. About one-third of the sample thought that it was important to take herbal medicines during labor (33.5%). Similarly, 31.2% (n = 59) of respondents thought it was good to take herbal medicines to hasten labor. Again the findings underscore the widespread use of oxytocics derived from local herbs, which because they cannot be carefully titrated, are known to contribute to poor pregnancy outcomes (ruptured uterus, tetanic contractions, overstimulation of the uterus, fetal distress, placental abruption).Malaria is a common health problem in Malawi. Almost the entire sample, 91.8% thought it was important for pregnant women to use antimalarials, with only 7.9% responding that taking antimalarials while pregnant was not necessary. More respondents (95.2%, n = 180) believed that it was important to take iron during pregnancy, whereas only 7 (3.7%) respondents did not believe taking iron was necessary. Most respondents (65%, n = 123) thought it was important to get the tetanus toxoid vaccine. However, of concern was the 18 (9.5%) respondents who did not know why it was important to get this vaccination, and the 15 (7.5%) who gave erroneous information about the use of the tetanus toxoid vaccine (such as to prevent measles, mumps, or other diseases).Most respondents (97.4%) thought that women should eat special foods while pregnant. One hundred fifty-two (80%) respondents thought it was important for pregnant women to eat vegetables while pregnant, whereas 109 (58%) thought eating fruit was important. Meat was reported by 98 (52%) respondents as being important to eat while pregnant, but other sources of protein such as beans (n = 53, 28%), fish (n = 28,15%), and eggs (n = 34, 18%) also were commonly mentioned. Commonly mentioned carbohydrates were nsima (n = 46, 24%) and maize (n = 4, 2%). There were some foods, such as orange soda (n = 12, 6%), that a small number of women believed were beneficial during labor but that do not provide nutritional value.Some traditional beliefs (such as a belief in bewitchment) that occur in Malawi are not as common in the United States but do exist among some immigrant groups (such as a belief in the “evil eye”). Among the survey respondents, many believed that it was possible to be bewitched during labor (51%, n = 97), whereas 43% (n = 81) did not believe women could be bewitched, and 3.2% said they were not sure (n = 6). Almost any complication of labor (such as prolonged pregnancy) could occur as a form of bewitchment, but the overall outcome of bewitchments is the belief that the mother or infant would get sick or die.A lack of postpartum care is of particular concern because leading causes of maternal mortality in Malawi include postpartum hemorrhage and postpartum infections, both of which may be limited with regular postpartum care.Although most women have accurate information about the need to take antimalarials and iron during pregnancy, some women still need this information. More importantly, there are many women who are misinformed about the use of the tetanus toxoid vaccine, and many women who attribute negative birth outcomes to bewitchment. Education could help women to seek help sooner when there are problems during pregnancy, labor or childbirth, rather than blaming poor outcomes on bewitchment. Education is important so that women can know what actions, such as taking antimalarials and iron, can improve pregnancy outcomes, and what actions, such as standing in doorways, are not as important in ensuring positive pregnancy outcomes. In addition, education is needed to increase the number of women who seek postpartum care. This lack of postpartum care is of particular concern because leading causes of maternal mortality in Malawi include postpartum hemorrhage and postpartum infections (12-24%, Ministry of Health and Population, 1995Ministry of Health and Population Safe motherhood needs assessment report. Author, Llongwe, Malawi1995Google Scholar, p. 19), both of which may be limited with regular postpartum care.Future DirectionsA train-the-trainer program is being conducted in which village women leaders are educated to provide health education to childbearing women in their villages. Future research plans include a comparative study to determine if health outcomes are improved in villages where this additional health education is provided. Members of the International Center of Research for Women, Children, and Families who also are faculty from the University of Pennsylvania, School of Nursing, a World Health Organization Collaborating Center for Nursing and Midwifery Leadership, and faculty from the University of Malawi, Kamuzu College of Nursing are committed to continued collaborative research and to continued endeavors designed to improve maternal and child maternal and morbidity.Our current collaboration has helped the involved nurses from both countries to more fully appreciate the universal desire of pregnant women to be delivered safely of a healthy infant. The cultural practices surrounding that goal are important for caregivers to understand as we work in partnership with women to improve maternal and neonatal morbidity and mortality in both countries. Health care for women and children, with specific attention to the reduction of maternal mortality and morbidity, is the focus of a partnership between faculty from two university schools of nursing, one in Malawi and one in Pennsylvania, and the Malawi Ministry of Health and Population. As part of this partnership, beliefs and practices of childbearing women in Malawi have been identified. Sensitivity to cultural beliefs and practices is central to the development of health care delivery systems that are acceptable to the patients they are designed to serve. Thus, knowledge of some of the cultural practices and their meaning in Malawi are not only helpful to clinicians in that country, but also provide all clinicians with an understanding of the importance of the cultural context within which health care is provided. Cultural sensitivity is especially important when caring for childbearing women because cultural traditions are fundamental to the way women choose to birth their infants. There are many similarities and great differences between childbearing in Malawi and the United States. In both countries, pregnancy-induced hypertension, premature labor and delivery, premature rupture of membranes, and ectopic pregnancies are prevalent health problems. The most common problem faced by neonates in both countries is preterm birth. In both countries, childbearing women and neonates are regarded as unique beings with physical, psychologic, social, and spiritual needs who need individualized and comprehensive care, and nurses use the nursing process to assess and intervene to provide optimal care. Health manpower shortages in Malawi have parallels to shortages in some parts of the United States, where geographic and economic barriers limit access to care. To maximize health manpower, all nurses in Malawi also are educated as nurse-midwives. Economic and Geographic BackgroundMalawi is a small, landlocked, developing country in South Eastern Africa, bordered to the north and northeast by the United Republic of Tanzania, to the east, south, and southwest by the People’s Republic of Mozambique, and to the west by the Republic of Zambia. The predominant vegetation is the savanna woodland, with evergreen forests in places where water is plentiful and grasslands located in high plateaus. Malawi is a former British protectorate; it became independent in 1964 and has a democratic government under the leadership of President Bakili Muluzi. The official languages of Malawi are English and Chichewa.The economy of Malawi
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