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Introduction: The understanding of the link between cultural affairs and maternal health is critical to save the lives of women. The South African maternal mortality rate (MMR) target for 2015 was 38/100,000 live births. In 2017, South Africa had 1,222 maternal deaths. The purpose was to determine the perceived cultural factors contributing to MMR in rural villages in Mopani District. Methods: This qualitative research and non-probability purposive sampling was used to select participants who met the inclusion criteria. Thirty women, age 40 years and above childbearing age, who had given birth in their lifetime, were sampled. Data were collected through in-depth individual interviews at the women’s homes. Probing to elicit more information was conducted focusing on hemorrhage, hypertension and risk of contracting human immunodeficiency virus (HIV). Data were analyzed through open coding methods. Trustworthiness was ensured by Guba and Lincoln’s criteria, credibility, dependability, confirmability, and transferability. Results: From the study three themes emerged from the data as cultural factors relating to heavy, red post-delivery bleeding perceived as cleaning-out of the womb. With hypertension, gaining weight rapidly before the 20th week of gestation not reported as a pregnancy was still culturally concealed. Contracting HIV, women were exposed to unsafe sex practices due to cultural expectations of having children as a sign of femininity. Discussion: The formulation of culture congruent interventions to promote good and acceptable cultural practices that cannot harm the physical and mental status of women was recommended to reduce unplanned deaths among them.
The study was conducted at the Ba-Phalaborwa Local Municipality which is located in Mopani District of Limpopo province, South Africa. There are two surrounding townships in Phalaborwa. A qualitative, exploratory and descriptive research approach was used. The population sample comprised of women who have passed childbearing age. Non-probability, purposive sampling was used to select participants who met the inclusion criteria. Thirty women, aged 40 years and above childbearing age, who had given birth in their lifetime, were sampled. In this study the ethical clearance was obtained from the University of Venda Research Ethics Committee (SHS/16/PDC/23/1008) and permission to access villages from the Tribal Authorities of villages. All procedures performed which involve the participants were in accordance with the ethical standards of the institutional and research committee and with the 1964 Helsinki Declaration. Informed consent was obtained from all participants. Participants were informed of their right to withdraw from the study without any penalty. Principles of fairness, privacy, confidentiality, anonymity as well as participants’ rights to voluntarily participate in the study were adhered to. Data was collected using in-depth individual interviews, guided by an un-structured open-ended question “Could you share with me the cultural practices that are practiced for women during the childbirth period in this area?” Open-ended questions gave the participants the opportunity of answering any question in their own words. Probing as communication skills such as reflecting, encouraging and paraphrasing were used to elicit more information and focused on hemorrhage, hypertension and risk of contracting HIV. Data were collected for a period of not more than 45 minutes at the participant’s home as per the appointments. Data was collected using Xitsonga and Sepedi as local languages. A voice recorder and field notes were used to capture data. The narrative data from the qualitative un-structured interviews were analyzed using Tesch’s open coding method.24 The method included the following steps: the researcher read carefully through all the transcripts to get a sense of whole. After the completion of reading all transcripts, a list of similar topics was compiled. Data were grouped per themes and sub-themes and field notes were also coded and categorized. A literature control was done to control the results of the study.25 Trustworthiness was ensured by applying four principles of Lincoln and Guba’s26 framework. Credibility was ensured through prolonged engagement, the researchers met with participants during first appointment, data collection and member checks. The experts used dependability to validate the methodology and this was ensured through thick description. Confirmability was ensured by adequate trail audit to determine the conclusions, interpretations and recommendations if traced to their sources. The participants were all females aged between 41 and 79 years. Nine participants were married, one widowed and two were single. All participants had borne children in their life time. Eighteen participants were of the XiTsonga ethnic group as this was the main cultural group in the villages selected and twelve were Northern Sotho (Table 1). Demographic Data for Participants (N = 30) Themes and sub-themes that emerged (Table 2) are discussed below. Main Theme, Themes and Sub-Themes That Emerged from the Data Analysis Cultural factors affect the utilization of maternity care services in developing countries. The notion was supported by Azuh27 when reporting that in parts of African countries, women had limited decision-making power in matters of reproduction and sexuality health. The author further corroborated that low status of women and the husbands’ domination could contribute to poor utilization of health-care services. Similarly, Hubert28 asserted that high levels of maternal mortality were strongly correlated with high levels of social inequality, especially unequal access to health services. The themes and sub-themes that emerged from the main theme (Table 2) will be discussed. Maternal hemorrhage encompasses antepartum, intrapartum, and postpartum bleeding. In an optimal setting, patients who are at high risk of hemorrhage are referred to tertiary care institutions which have multidisciplinary teams who are prepared to care for and deal with known and unknown potential complications. Most participants conveyed that they do not know the actual difference between hemorrhage and normal bleeding which is known as lochia post-delivery. Socio-cultural factors may primarily influence decision making on whether to seek care, and to reach a care facility in time.29 In an African rural setting, knowledge to seek care lies firstly on cultural views. Culture often determines how individuals view diseases, and other related conditions. Some individuals would first seek care at churches and traditional healers since one may believe that it is spiritual work and not ordinary conditions which may need medical attention. Participant number 02 supported this when saying that: During pregnancy every time I fell sick or feel unwell, I first use church tea which I drink almost every day or herbs, then if the condition does not change I go to church to talk to the elders and the pastor for stronger herbs and prayers. I only visit the clinic if the situation gets worse. Participant number 03 supported this by saying: “We have a very strong traditional doctor around here. Since I was bleeding during my 2nd trimester, it was believed that my enemies wanted to take my child away and use him/her against me. But days later I bled more. I was taken to hospital, and I lost my baby.“ Amongst African rural communities, people perform rituals and undertake consulting with traditional doctors for medications in the belief that they heal better than western medication. These practices are deeply rooted and embedded in these societies, and therefore they become part of the people’s lifestyle. It was noted that community members were innate to such an extent that it was difficult to change the beliefs and practices, as they adhered to them throughout their entire lives. Individuals adhered to their grandparent’s knowledge in the belief that they know better since they were there before them. Participant number 01 indicated that: “Few days after giving birth, I had cramps and started bleeding profusely. My grandmother said it was a good sign that all pregnancy particles were coming out of my body. And with cramps she said that it was because that maybe I gave birth on the bed which a woman had miscarriage on previously. In turn if no medical attention is given, implications on the health status of the individual may be severe. The mother was experiencing post-partum hemorrhage which, if left untreated, might have caused her to bleed to death. Participant number 11 indicated that: “After my younger sister gave birth, she was bleeding; I thought she wasn”t stitched properly since she had an episiotomy. But then my mother insisted that we take her to a traditional doctor as it was believed that if this condition is treated medically one will always fall sick. So my family took her to a traditional healer so that in future that condition may not happen. She stayed at the traditional healer’s house. But after a few hours we were called back and told that she had passed on. Postpartum hemorrhage can lead to maternal death within hours, and this can be worse if there is a delay in recognizing emergency obstetric complications and making prompt decision to seek care. Hypertensive disorders of pregnancy contribute to severe morbidity, long-term disability and death among both mothers and their babies. However, deaths due to pre-eclampsia and eclampsia could be avoidable through the provision of timely and effective care to the women presenting with these complications. Delay in medical attention has negative effects both on the fetus and the mother. Early detection of hypertension is important for assuring appropriate management and referral of women at risk of developing eclampsia including appropriate treatment. However, the traditional beliefs tended to cause delay in seeking medical attention, as elders were perceived to know much better about medical conditions, hence they would do what their elders did and how their culture was practiced. Participant 15 indicated that: “In my family we have one or two kind of herbs which can help heal a sick patient. Since I am overweight, during my third pregnancy I developed swollen feet. My grandmother would pour the herbs in a bowl and tell me to soak my feet. But that didn’t help; I had to visit the clinic 3 days later. Fraser et al,16 pointed that weight gain during pregnancy comprised the products of conception (fetus, placenta, and amniotic fluid) and hypertrophy of several maternal tissues (uterus, breasts blood, fat stores and extracellular and extravascular fluid). The authors further indicated that optimal weight gain for an average pregnancy is 12.5 kg, of which 9 kg is gained in the last 20 weeks of pregnancy. The fluid retention can further add up to 25% of a pregnant woman’s weight. Decision making among black African communities lies mostly with the men, as the patriarchal system still dominates even to this day. Women have limited decision-making abilities on their reproductive and sexual health. As a sign of respect, women have to be submissive to their husband and this can also contribute to maternal morbidity and mortality. Participant number 10 indicated that: “I have a lot of jobs to do daily. I clean the yard and the house. Cook for my 5 children and husband, do laundry and other things. I cannot just go to the hospital. If I just leave, who will take care of my husband and children? When I am sick, I try to be strong just for my family. My husband is the one who gives me permission to visit the clinic since it is a bit far. It is only during antenatal period of pregnancy that I can go to the clinic at due time, but I go there early so that by noon I’m back.” The results of the study by James et al19 indicated that swelling of the legs was associated with superstition. Complications of hypertension in pregnancy remained the common direct cause of maternal deaths. Fraser et al16 pointed out that normally 9 kg is gained in the last 20 weeks of pregnancy. When the woman gains weight rapidly before the 20th week of gestation that should be investigated. Furthermore, cultural factors apparently affect the utilization of maternity care services in developing. Polygamy is a common marital practice for many African cultures.30,31 Certain prevalent cultural norms and practices related to sexuality contribute to the risk of contracting HIV/AIDS. Some participants indicated that they practice culture so that they may not cause feuds between family members. Some practices which includes polygamy or bearing children for your sibling. This practice could result in power inequality and engaging in unprotected sex, as women have limited ability to negotiate protected sex. Sub-themes that emerged are discussed below. The importance of fertility in African communities may hinder the practice of safer sex. It was understood that if one does not bear children, the in-laws may chase away the woman or even encourage the husband to get himself another wife. This exposes one to unsafe sex practices due to cultural expectations of having children as a sign of femininity. Such practices may lead to polygamy which is now less practiced in the rural area, yet men tend to have more sexual partners. This is a myth with goes that men biologically are programmed to need sex and one woman cannot satisfy them. Participant number 20 indicated that “As a wife, you should do what is expected of you. Most marriages without children, do not survive. Children are the foundation of the marriage. The man negotiates for sex and you do as he says. Obeying your husband makes the marriage strong” And while participant number 13 indicated that: It is culturally acceptable to bear children for your sibling. If your sibling cannot bear children, you have to sleep with her husband to bear children to them. If you disagree the family might take it that you are jealous of their marriage. For most of the ethnic groups, the husband has been assumed to be head of the household. The husband had dominance in decision making in the family including when he will have sex with his wife or wives. Negative attitude towards use of condoms influences individuals on refraining from using condoms. It was emerged that “Flesh to flesh” sexual activity gives more pleasure than using condoms. Participant number 19 indicated that: “Lack of trust is associated with use of condom. Initiating to use a condom means that you do not trust your partner and I feel like there is no need for me to use a condom because I trust my husband and he trusts me too”. While participant number 16 stated that: “My man complains that condoms interfere with sexual pleasure, they deter sexual activity by reducing sensitivity and sometimes causing dry sex. He always tells me a quote in which he says “how can you eat a sweet in a plastic?” A condom in which he refers as a plastic …. Participant number 08 indicated that: It is embarrassing to purchase condoms. The cashier looks at you in a nasty way. Even at the clinics, when I take my child for immunization, I only take the condoms when nobody is looking.
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