Traditional practices during pregnancy and childbirth among mothers in Shey Bench District,South West Ethiopia

Abstract

Objective:

Pregnancy and child birth is the most critical period in the health of women and children and the objective of this study was to explore traditional practices among mothers during pregnancy and delivery in Shey Bench District, South West Ethiopia, and we hope the evidence generated could benefit decision-makers and concerned bodies who are interested in this important public health issue.

Methods:

A descriptive qualitative study, which is an ideal approach when an uncomplicated description is desired that focuses on the details of what, where, when, and why of an event or experience, was conducted from March to May 2019 in Shey Bench District and a purposively selected 43 women have participated in the study. In-depth interviews and key informant interviews were conducted and data were analyzed by Open code 4.2 software and summarized following content analysis approach. Findings were narrated based on the major categories and study participants’ words were used as quotes.

Results:

In this study, it was found that mothers have experience of traditional practices mainly of abdominal massage, use of herbs, prohibition of some food types, and strenuous physical exercise during pregnancy and childbirth. As of the reasons; mothers reported as traditional practices help them to make the labor easy and fast, alleviate discomforts, and avoid unwanted big size of the fetus. Experience of health problem following practice of traditional practices like vaginal bleeding and child death were also reported. However, some study participants indicated as community members are changing their mind because of getting advice from health professionals.

Conclusion:

Although traditional practices were found to be exercised by mothers believing to get benefits, there were reports of health side effects on mothers and the fetus from applying abdominal massage, herbal medicine, food prohibition, and strenuous physical exercise during their pregnancy and childbirth. Therefore, concerned working bodies shall design and implement necessary interventions, particularly health education programs to bring a better a change against harmful traditional practices.

Introduction

Background

Traditional cultural practices reflect values and beliefs held by members of a community for periods often spanning generations, which are followed by different population groups and such practices could be beneficial, harmful, or neutral. There are reports as women experience certain beliefs relating to diet, behavior, use of medicinal herbs, and massaging the abdomen during their pregnancy and child birth. ¹ It is advisable to promote beneficial cultures and discourage those which have negative impact on mothers and the fetus. ² Practices related to the perinatal period continue to be sustained by societies, even though they show intercultural differences and change over time in the same cultures. ³

There are women who preferred and had regular abdominal massage in concurrent with antenatal^4,5 and also there are cultures in which women rub abdomen into a wooden post to facilitate delivery of the fetus. ⁶ A study from Ethiopia has also showed that pregnant women practices abdominal massage to get relief from pregnancy-related complications, and for that, the majority of pregnant women get some kinds of admiration and support from traditional birth attendants, families, and neighbors to carry out such practices to solve their pregnancy-related problems. ⁷

Food taboo is a traditional practice in which nutritious and safe food types may be restricted or denied thus making women vulnerable. ⁸ Studies revealed that as mothers avoid to eat beans, eggs, fish, meat products, potatoes, fruits, butternut, and pumpkin, which are rich in essential micronutrients, protein, and carbohydrates.^9–11 Studies from Ethiopia have also showed experience of food taboos by mothers during their pregnancy period. Types of food items considered by pregnant mothers include linseed, coffee, tea, cabbage, porridge, wheat bread, banana, pimento, pepper, groundnut, salty diet, nug, sugarcane, pumpkin, and coca drinks. The reasons behind the food taboos were fear of difficulty in delivery, fear of prolonged and pain labor, fear of abortion and miscarriage, large fetus, and feeling of indigestion. In addition to this, other respondents also argued that foods such as milk and milk products are taboo because it sticks on the fetal head and face of the fetus.^7,12

Herbal medicine is another tradition commonly used during pregnancy.^13,14 Nausea, abdominal cramp, and common cold were some of the common indications to use herbal medicines during pregnancy. Ginger, cranberry, valerian, and raspberry were the most commonly used herbs in pregnancy. ¹⁵ A study from Ethiopia has also reported use of herbal medicine during pregnancy and most commonly consumed herbal medicine includes ginger, damakasse, garlic, tenaadam, and eucalyptus but is not known that these most commonly consumed plant species have harmful fetal effects. ¹⁶

There are areas where mothers may be advised to have extraneous physical exercise, work, and lifting heavy loads during their pregnancy period. However, studies have also showed as lifting in combination with job strain could increase the risk of poor pregnancy outcome like preeclampsia, gestational hypertension, gestational diabetes, birth complication, and low birth weight.^17–19

Despite some perceived potential beneficial effects, cultural practices during pregnancy may have harmful effects on both mother’s and baby’s health which demands detail understanding of the reasons behind to recommend the right measurement for encouraging the beneficiary ones and discourage the harmful ones.^1,3 There are a few studies from Ethiopia which addressed such issues at different time but most of the studies focused on single issues and are more of figurative reports than understanding the details of the traditional practices. However, there are no studies from southern parts of the country, particularly in the South Western region where many culturally diversified people including pastoralist communities live. Hence; it is very important to reach these community members and generating evidences through appropriate approach, especially qualitative study is demanding. Therefore, this study was conducted to explore the experiences and reasons why mothers exercise different traditional practices during pregnancy and childbirth.

Methods

Study area and period

The study was conducted from March to May 2019 at Shey Bench District which is part of Bench Sheko Zone. The capital of the zone is Mizan Aman town and located around 585 km away from Addis Ababa. Bench Sheko Zone is one of the zones in the south western Ethiopia which has culturally rich, multi-linguistic, and diversified people. Hence, studying traditional practices in such culturally rich area was found to be reasonable. According to the information gained from the zonal health bureau, the zone has two town administrations and 6 rural districts with total of 625,345 residents, 1 teaching hospital, 26 health centers with 904 health professionals, and 224 health posts with 567 health professionals. Shey Bench District is one of the semi urban woreda which has a total population of 145,569 (72,057 males and 73,512 females). This study was conducted in two kebeles called Maz Kebele, which has 7811 total population and Kusha Kebele, which has 5523 total population.

Study design

A descriptive qualitative study, which is an ideal approach when an uncomplicated description is desired that focuses on the details of what, where, when, and why of an event or experience, was conducted. Scholars have reported as the goal of qualitative descriptive study is a comprehensive summarization, in everyday terms, of specific events experienced by individuals or groups of individuals. It is an approach that is very useful when researchers want to know, regarding events, who were involved, what was involved, and where did things take place.^20–22 Again, its flexibility nature as research questions and study findings emerge also makes it to be elective. Hence, this study approach was found to be appropriate to understand the traditional practices among mothers during pregnancy and childbirth in the selected multicultural area.

Sample size and sampling procedure

Applying a purposive sampling method, we selected mothers who have experience of child birth and use of different traditional practices during their pregnancy period. In the beginning, we contacted health extension workers in the study area and made a discussion about how to get mothers who could give better information on experience of traditional practices during pregnancy. Following that, we conducted in-depth interviews among 34 mothers and a key informant interview among 9 mothers who had experience of performing traditional practices for pregnant mothers in the area. These nine mothers were selected purposively to learn their experience of what cultural practices, how, why, and for whom do they apply and what consequences have they ever faced or witnessed. Throughout the data collection process, we considered saturation of the information to decide on the sample size. Accordingly, we have learned that the categories were well developed and no new ideas were reported after reaching the given sample size.

Source population

The source population were all reproductive age group women, who had pregnancy and gave childbirth within 2 years in the study area and women who have experience of performing traditional practice or traditional birth attendants as witnessed by local leader, health extensions, and mothers.

Study populations

Women who reside in the selected area and had experience of child birth at least one time and above within the 2 years prior to the period of data collection, and again women who had experience of performing traditional practices during pregnancy and child birth and who lived in the area at least more than 1 year were the study population.

Inclusion and exclusion criteria

Inclusion criteria

• Women who reside in the selected area and had experience of child birth at least one time and above within the 2 years prior to the period of data collection period were the study population.

• Women who had experience of doing traditional practices during pregnancy (get information/witness about them from local leader, health extensions, and mothers) and child birth who lived in the area more than 1 year.

Exclusion criteria

• Women who were mentally incapable and those who were unable to communicate were not part of the study.

Definition of traditional practices

• Harmful traditional practice: all practices done deliberately by untrained person on the body or the psyche of women for no therapeutic purpose, but rather for cultural motives and which have harmful consequences on the health and the rights of the victims.

• Abdominal massage: rubbing butter/oil and massage over the abdomen area of pregnant women by non-professionals.

• Food prohibition: traditionally forbidden food which is enforced against women during pregnancy and delivery.

• Herbal medicine: any plants and related things taken during pregnancy and delivery assumed to have medicinal effect.

• Extraneous physical activities: any physical activities (not science based) and movement and/or holding materials or lifting objects which are heavy like fetching water and wood believing that such things benefit pregnant mothers.

Data collection procedures

An interview guide, translated to Amharic language, was used to collect data from study participants. The interview guide was developed based on the objective, findings of previous studies^{12,16,23–25} and enriched by information gathered by principal investigators while facilitating the data collection. The major discussion points include kinds of traditional practices, how and why traditional practices are conducted, who does the traditional practices, when and for whom do traditional practices are done, what beneficial and or harmful experiences were there relate to the traditional practices, what do people suggest regarding traditional practices, and what is expected? Two research assistants who are healthcare workers with other four health extension workers facilitated the data collection. Study participants were selected by moving home to home, and interview was held at quite place around their home. All data were collected by principal investigators (both have master’s degree in Public Health and experiences and trainings in qualitative research). The interview has taken an average of 36 min.

Ensuring trustworthiness

Throughout the interview; data collectors have approached participants very friendly and developed rapport. Have informed and discussed in detail about the research goal and process. Interviews were audio recorded and kept for cross checking as needed. Debriefing and feedback from colleagues were used in managing the data. The inquire process and findings were described in detail so that any interested one could benefit from it. Documents of all the study process were kept and colleagues were let to see the neutrality and dependability of the data. A code–recode process was done on separate time and checked for similarity of codes for intra- and inter-coder dependability. Confirmability was maintained by audit trial, and participants’ words were quoted in writing the findings. Throughout the study process, researchers’ experience and thoughts regarding the study topic were clearly reflected.

Data analysis

Data analysis was done simultaneously with data collection. The information stored on audio recorder was transcribed verbatim with due consideration of field notes. Investigators (two in number) developed codebook and made discussion on the coding process. Repeatedly reading the data and being immersed in it; coding and categorization were done using Open code 4.2 software. Bringing the most related issues together, content analysis was applied to summarize the findings.

Study results

The findings of the study are summarized under major categories of: socio-demographic characteristics, experience of traditional practice, and types and reasons for harmful traditional practices (abdominal massage, prohibition of food, taking different herbs, and doing extraneous physical exercise).

Socio-demographic characteristics

Thirty-four mothers have participated in in-depth interview and nine women were interviewed in key informant interviews. The age of participants ranges from 23 to 52 (elders were key informant participants) and majorities (38) were married, housewife farmers, and did not attend formal education. Key informants had experience of supporting mothers during delivery, acting as traditional birth attendant.

Experience of traditional practices

Abdominal massage, prohibition of food, taking different herbs, and doing extraneous exercise were the major traditional practices reported by study participants. Almost half of the participants had discussed that they used to practice for themselves and do it for others too during pregnancy time and childbirth. However, some of them had reported as they used to observe but did not experience. Again, few of the study participants had explained as they still experience some of the traditional practices. Of course, some participants had reported that these practices were more common formerly than in the recent time because of getting different advices from health professionals.

Types and reasons for harmful traditional practices

Study participants had discussed on the reasons why traditional practices are exercised during pregnancy time and child birth. Accordingly, many reasons were pointed out for each of the commonly practiced traditions and here below discussed under four main categories.

Category 1: abdominal massage

One of the mainly reported traditions was abdominal massage, and it was indicated that mothers apply it targeting to get relief from pain, to correct fetal position, to ease and fasten labor, and to get comfort, when they sustained a fall down accident and when they assumed that the fetus has displaced. It was reflected that abdominal massage is usually done if mothers sustained a fall down accident and mothers believe massaging the abdomen helps to correct the position of the fetus. Abdominal massage is also conducted to facilitate labor, and it is done by someone assumed to have experience or even the one who did not have. The process involves cleaning the abdomen, applying butter or oil on the abdomen, and then rubbing or massaging it by the palm for short period till the position of fetus is assumed to return to right position, labor gets fast, or the pain relieves. The following points are parts of the responses from the study participants regarding this practice:

Abdominal massage is usually done with intention of correcting the position of the fetus in the womb. In addition it is believed that, if a woman had abdominal massage, her labour could be hastened and be easy. (A 50-year-old Key informant woman)

What I know is; if a woman sustained fall down accident, it will be assumed that the fetus may leave its right position/displaces to one side and it will be returned to its right place by massaging the abdomen. So people do that. I know a woman who sustained vaginal bleeding after she had had abdominal massage during her pregnancy of around three months but later she went to clinic and got treatment. And the fetus was aborted at clinic. (A 30-year-old in-depth interview participant woman)

I had experience of abdominal massage during my pregnancy; it was done after I had sustained fall down accident. During that time people told me as the fetus has displaced from its right side and they told me massaging the abdomen will returns to its right place. Then I went to an elder woman who has experience of this and she massaged my abdomen by applying a butter; then after I felt well. (A 27-year-old in-depth interview participant woman)

However, mothers have also discussed as they are avoiding this experience nowadays because of getting support and advice from health extensions and other health professionals. One of the study participants has explained it as follows:

Formerly I used to perform abdominal massage, I used to assist labour at home but now I don’t do it. Now I advise women to visit health centers or hospital for her health. (A 50-year-old Key informant woman)

One unique finding mentioned to be a reason for abdominal massage was related with the intention of treating a health problem what the study participants called heart displacement (locally called Bu’i):

Abdominal massage is also done when people assume that there is bu’i (assumption of heart displaces to lower body or abdomen) and the massage is exhaustively done with the assumption of returning heart to its right place. (A 34-year-old in-depth interview participant woman)

Most of study participants have agreed as such tradition has no benefit and wish to stop and also advice for that. Of course, there are also a few participants who support to have it and who still recommend to have it. The following two responses are reflections regarding this concern:

Massaging the abdomen has no benefit; I have seen it and I got relieve from clinic. (A 34-year-old in-depth interview participant woman)

If abdominal massage is done by those who are well experienced is good. And I wish so as it continues because I saw it helped me. (A 30-year-old in-depth interview participant woman)

Category 2: extraneous physical activities

Regarding extraneous physical activities and or heavy work during pregnancy; participants had explained as it is believed that if a mother does exercise, she might give a birth easily and within short period of time. As a result, mothers used to be encouraged to go long distance walk, lift heavy load, fetch water, and collect wood outdoor. They have also pointed out that heavy work is not advised during first period of pregnancy, because it may leads to vaginal bleeding and pain but when a woman reaches to labor, doing heavy work is believed to be good thinking it hasten labor and makes labor easy. The following points were parts of the responses from different study participants:

I know that pregnant women are advised to do heavy work and go long distance on feet. (A 42-year-old Key informant woman)

When time of delivery reaches a pregnant mother does heavy work. It is advised because people believe that it hastens labour. (A 30-year-old in-depth interview participant woman)

Doing heavy work is good for pregnant mothers because it hastens labour. Again in our community it is also said during first pregnancy a woman should not go to clinic early because her labour may take long time and she shouldn’t stay long time out of her home. (A 32-year-old in-depth interview participant woman)

Very few study participants have reported as they have witnessed women who have experienced health problems like child death/still birth and even mothers giving birth alone in the field because of engaging in heavy work and have advised to avoid it. Up on summarizing their ideas, almost all study participants have pointed out as such practices might have health impact than the assumed benefit and have advised to go to health facility to make labor easy and secure health of mothers and new borns:

It is a long time but now one woman who had delivered in the field while she was collecting wood and it was difficult for her. (A 38-year-old in-depth interview participant woman)

Category 3: food prohibition

Different food types were mentioned which are recommended to be taken and/or to be avoided during pregnancy. Most of the participants had explained that pregnant mothers require additional food and should be allowed to take all food items, especially meat products. However, few had discussed that, there are food types which are believed to cause problems on mothers and the fetus, as a result, a pregnant mother should not take them. Two of the study participants shared the following points:

We advise pregnant women should have good diet otherwise labour could be prolonged and mothers could be fatigued during labour. (A 42-year-old Key informant woman)

I heard that a pregnant mother should not eat a pepper because it leads for loss of hair of a baby. (A 28-year-old in-depth interview participant woman)

It was reported that linseed (telba) is good for hastening of labor, and for that reason, mothers usually drink it when their laboring time reaches and labor starts them. However, sugarcane and godere (local food) are not advised for pregnant mothers because of assuming a baby might get fat and could not be delivered at it is time. Yogurt was also mentioned as it is not good because it may be attached to the fetus and difficult to separate from baby’s body. People also advise pregnant mothers to take linseed as liquid form believing that it makes the baby to move well in the abdomen and also it helps to hasten the labor:

During my last period of my pregnancy people advised me to take linseed in liquid form because they suggested me as it hastens labour and make it easy. I took it when I reached 9 month of age and my labour started. (A 35-year-old in-depth interview participant woman)

What I know is that sugarcane, egg, pumpkin and godere (local food like potato) are not good because a baby may get big and godere may also be attached to the baby. (A 25-year-old in-depth interview participant woman)

Category 4: use of herbal medicine

Herbal medicine or taking plants for medical purpose was also one of the traditions reported by few of the study participants. Accordingly, roots and leaves of plants were mentioned to be used at different times during pregnancy and child birth as well with the intention of treating some illnesses and preserving health of mothers and fetus. The herbal medicines are prepared at home or some may be collected from persons who are thought to have experience in it. A few of the study participants have discussed their experience in taking roots and leaves of plants but also reported no history of complication related to consuming them. Based on their experience, they have reported that such trends are getting to be neglected since most mothers have developed culture of visiting healthcare facilities and discuss with nearby health professionals, particularly with that of health extension workers. Study participants have shared the following points regarding the issue:

When one woman reaches to her labouring time roots, of plants is given to her because we believe that it makes labour easy. (A 25-year-old in-depth interview participant woman)

People advise pregnant mothers to take a liquid made from different leaves because it is believed that it makes the baby to move well in the abdomen and also it helps to hasten the labour. (A 35-year-old in-depth interview participant woman)

Discussion

Through this study, commonest traditional practices during pregnancy and reason behind practicing them among mothers were explored. Accordingly, it was found that abdominal massage, food prohibition, taking herbs, and doing extraneous physical exercise during their pregnancy and delivery were commonly reported practices. As of the reasons: mothers have discussed that such traditional practices help them to make the labor easy and fast, alleviate discomforts, and avoid unwanted big size of the fetus.

There are a study reports which show as abdominal massage done by non-professionals is dangerous for mother and fetus. It was reported as it may result in abruption placenta, uterine rupture, fetal morbidity, fetal mortality, maternal morbidity, and maternal mortality.^4,5 In this study, abdominal massage during pregnancy was reported to be one of the traditional practices which used to be more commonly applied and became limited to be practiced by few of mothers in recent times, comparable results were reported from Ethiopian studies done in Limu Genet, Debark, and Debretabor, where some mothers reported history of abdominal massage.^23,25,26 This might happen due to closeness in socio-demographic characteristics and social norms. However, the finding of this study was somewhat different than Nigeria’s study finding in which only very few mothers have described as they had experience of abdominal massage, ²⁷ it might be explained by differences in study populations’ exposure to healthcare service and information regarding such practices. As far as different scholars suggest that experience of abdominal massage could result in bad outcome for mothers and fetus, the finding of this study implies as mothers might suffer from their abdominal massage practice and it is a demanding issue for taking action.

Use of herbal medicine, none specified types of roots and leaves of plants, was reported by few of study participants. There are studies which report as herbal medicines are not necessarily safe alternatives to conventional medicines during pregnancy because their constituents are likely to have pharmacological activity and they might possess toxic constituents.^4,28 Reports from Ghana and Asian countries have also indicated that pregnant mothers have culture of using herbal medicine.^29,30 Comparing with a study conducted in Gonder, where half of study participants reported utilization of herbal medicine, ²⁴ our finding showed limited experience of using herbal medicine during pregnancy and child birth. The difference could result from cultural dependency and health-seeking behavior variation too. Study participants from this study reported as they visit health center/post and use of herbal medicine nowadays is reducing.

Experience of restriction to some food items like sugarcane, yogurt, egg, peppers, pumpkin, and godere (local food like potato) was mentioned by some of study participants. Studies from Limu Genet of Oromia region, Amhara region, and Afar region of Ethiopia have also reported as 1/5th of women had experience of food taboo.^23,25,31 The similarity could be explained by comparability of the study setting and study population background in terms of healthcare-seeking behavior, access to health information, and compliance to recommended health messages. However, studies from Debretabor town of Amhara region and Shashemene of Oromia region had also reported near to half of women had nutritional taboo.^26,32 The gap might be due to differences in time of study and setting as well. Studies from Ghana, India, Madagascar, and Kenya^8,30,33,34 have also reported different levels of food taboos among mothers during pregnancy. Similar food items were reported through these studies which are usually avoided by pregnant mothers, mainly including animal products. The reasons mentioned behind avoiding some food items are related with different misperceptions which demands effort in order to change for better.

Experience of lifting and carrying heavy load and or extraneous physical activities during mothers’ pregnancy time was reported by few of study participants. Vigorous physical exercise which is not supported by experts and not scientifically sound is not advisable.^35,36 However, this study identified as women have experiences of having vigorous exercise because of different thoughts like to make labor easy and fast, but at most time, it might end in bad outcome. Similar report was made from Turkey where a few mothers experience jumping from a high point assuming that it helps them to facilitate labor and make it easy. ³⁷ In this study; a few mothers have discussed that mothers are advised to do heavy work at different time of their pregnancy duration which implies that mothers are taking risk. Therefore, it needs attention and strong work should be done to make them understand its impact and take corrective measures.

Generally, although there are indications of reduction in experiencing harmful traditional practices, it is still an area which demands great attention in order to empower women and community members so as they could be able to bring a better change in terms of avoiding harmful traditional practices during pregnancy and child birth. It is important to improve health-seeking behavior, especially to promote antenatal care, which is the golden opportunity to address many of health-related issues during pregnancy, child birth, and even to postnatal period.

Limitation of the study

This study is not free of limitations and indicative that includes we did not get chance to observe none of the listed herbal medicines, kinds of prohibited food items, and even did not get chance to observe how abdominal massage is really done and kinds of strenuous physical exercise. Again, since we did the interview with health extension workers, participants might hide some issues they thought not accepted by their health extension worker, which seems social desirability bias.

Conclusion

In this study, it was found that experience of having abdominal massage, use of herbal medicine, prohibition of food, and experience of extraneous physical activity during pregnancy and child birth should not to be undermined although it is getting reduced. There are also mothers who reported pregnancy-related side effects from experiencing different cultural practices during their pregnancy and child birth period. However, having some awareness of their impact and presence of indications for reducing such harmful practices is one good lesson, but again it is important to give more adequate attention and implement necessary interventions to bring a better change. Therefore, it is recommended to have a health education program which targets addressing the major reasons which push mothers to have such harmful traditional practices.

Supplemental Material

sj-doc-2-smo-10.1177_20503121221098139 – Supplemental material for Traditional practices during pregnancy and childbirth among mothers in Shey Bench District, South West Ethiopia

Supplemental material, sj-doc-2-smo-10.1177_20503121221098139 for Traditional practices during pregnancy and childbirth among mothers in Shey Bench District, South West Ethiopia by Nahom Solomon and Melkamsew Tesfaye in SAGE Open Medicine

Supplemental Material

sj-docx-1-smo-10.1177_20503121221098139 – Supplemental material for Traditional practices during pregnancy and childbirth among mothers in Shey Bench District, South West Ethiopia

Supplemental material, sj-docx-1-smo-10.1177_20503121221098139 for Traditional practices during pregnancy and childbirth among mothers in Shey Bench District, South West Ethiopia by Nahom Solomon and Melkamsew Tesfaye in SAGE Open Medicine