Pregnancy, childbirth, mother and child care among the indigenous people of Zimbabwe

275

.I G~~r7oecol. Ohsrer.. (1985) 23: 275-285 fnrrrnstional Federation oiCyn~ecology & Obstetrics

I17r.

PREGNANCY, CHILDBIRTH, PEOPLE OF ZIMBABWE*

MOTHER

AND CHILD

JANE MC’TAMBIRWA

CARE

AMONG

THE INDIGENOUS

Introduction

L’ui~.ersifl. o,t’Ziurbabu,e, Harare (Zimbabrcr)

Abstract Mutambirwa J (University of Zimbabwe, Harare, Zimbabwe). Pregnancy, childbirth, mother and child care among the indigenous people of Zimbab we. Int J Gynaecol Obstet 23: 275-285, 1985 Even in areas of Zimbabwe with easy access to Western-type delivery care, the majority of women are cared for and delivered by traditional birth attendants who are members of their extended family. To understand the social, cultural context of pregnancy, childbirth and subsequent maternal and child care and to use this information for the improvement of maternal and child-health care an anthropoligical investigation was conducted in an area near Harare, Zimbabwe from June 1983 to the end of 1984. Certain aspects of childbirth such as primagravida deliveries and the origins of peripartum complications, are intimately linked to the religious beliefs and values; other aspects such as the relationship of nutrition and pregnancy are not so linked. An understanding of the traditional concepts of pregnancy, delivery and child care is invaluable if not essential for the upgrading of pregnancy and delivery care, the elimination of harmful practices and the building of supportive links between the traditional and the formal health system. Keywords: Traditional practices; Pregnancy: Delivery care: Child care; Traditional birth attendants. *From the Collected Papers of the Joint WHO/FIG0 Task Force ,for the Promotion of bfaternal Child Health including Family Planning in PrimaT Health Care. 0020-7292/85/503.30 Q 1985 International Federation Published and Printed in Ireland

The purpose of this paper is to present an overview picture of the belief system of Zimbabwe, some of the health practices and beliefs affecting childbearing period and the traditional midwifery care. These issues came to light in the course of a study of childbearing, child-rearing practices and mother and child care health in Chikwaka, a communal land, one of the 55 rural districts of Zimbabwe. At its nearest point Chikwaka Communal Land is about 40 k from the capital city of Harare. It stretches in a north-easterly direction to cover an area of about 298 sq k. The area includes arable, waste and range land. At the time of the study the population of Chikwaka was estimated at 19,000 people spread out in 148 villages. There is easy access to Harare’s health-care facilities and the district is served by three health centres as well. The people ofchikwaka belong to the Shona group which constitute about 90% of Zimbabwe’s indigenous population. The major findings of the Chikwaka study have since been tested in the field for their applicability in Zimbabwe. From June 1983 to date, all concepts, religious beliefs and value regarded as significantly influencing behavior and attitudes toward health and illness have been presented and discussed at national, provincial and district health workshops, conference, symposia and research groups at which staff and local community participants from all main ethnic groups in Zimbabwe are present. The field testing has shown major findings of the study to be concordant with those of the Ndebele people (who constitute about 10% of indigenous Zimbabweans) as well as other Africans of Bantu origin. Before the advent of western medicine, the 1ntJ

of Gynaecology& Obstetrics

Gynaecof Obsret 23

276

Mitambirwa

traditional health-care system provided healthcare services which have persisted to date. The Chikwaka study clearly shows that there are two health-care systems in the local communities of Zimbabwe today. These are the traditional and the western health-care delivery systems. Each system has its own health values, principles of hygiene, ideas and beliefs on pathology, aetiology, the transmission of diseases and their treatment. Traditional beliefs and health In the local cultures of Zimbabwe, religious beliefs, concepts of health, disease, human growth and development and the hereafter are intricately interwoven into a comprehensive approach. In the local tradition health is measured by observing the developmental tasks and stages accomplished in each phase of man’s growth and.development in the life cycle which begins from conception and continues to eternity. The aim of human growth and development in the life cycle is to lead the individual toeternal life which is achieved when the person’s soul reaches the ancestor spirit stage of growth and development. Developmental cycle In local traditions mankind is believed to be made up of three parts: the body, the soul (or mind) and the spirit (or conscience). The body is viewed as the perishable entity of man. It is merely responsive to the needs of the mind or soul throughout the physical part of the life cycle. Its functions are associated with the physical world. The soul is viewed as the immortal component of man’s constitution. It is not seen to perish like the body. The soul is seen to continue functioning during and after death of the body. The functions of the soul are associated with the social environment. The spirit is viewed as the eternal element of mankind’s constitution. The restraining and inhibiting functions of conscience upon a person’s behavior are seen as pure and sacred. Purity and sacredness are believed to be the ultimate states of wellbeing. Thus it is believed Int J Gynaecol Obstet 23

that in this ultimate state of health the spirit cannot be touched by evil or ill. It exists in eternal health. The functions of the spirit are associated with the spiritual environment. Human growth and development Traditional beliefs recognize eight phases of growth and development in the human lifecycle which are viewed from a religio-physical angle. The beginning of the first phase is diagnosed in religio-physical symbols. On the night of consummation corn seeds (symbol of fertility) are placed under the nuptial mat. The following morning a paternal aunt or grandmother examines the seeds for blood stains. The blood stains are symbolic of virginity which is associated with moral purity, and in turn, indicates good personal hygiene. This implies a disease-free consummation which is believed to engender disease-free offspring. The second phase is the period between birth and puberty. It is the phase in which the foundations for physical, mental, social and spiritual (i.e. moral) hygiene are laid down by adults in the family, who are considered responsible for invoking the guardian spirits to protect the child against diseases perceived as potential threats to the individual’s progression to the ancestor spirit stage. The third stage, influenced by the degree of success of the previous phases, is the period of social growth and development. This period begins with puberty until the first conception. Youths in this phase are expected to have learned how to survive in the physical world and to adapt to social situations with minimum assistance from the family. They are expected to apply the principles learned in the second phase towards a morally-hygienic existence. This in turn assures their physical health and no intercession is considered necessary. The fourth phase is the period of the first childbearing cycle. It is the phase of spiritual or moral growth and development, when spiritual influences are actively involved in establishing a lasting relationship with the individual. These influences are believed to facilitate early conception of the first offspring and to ensure a healthy and successful labor and

Pregnancy.

delivery. The family clan collectively coach the young adult on lores of the family spiritual links. The young men and women in this phase are thus prepared for spiritual, social and physical parent hood. It is believed that a person learns moral hygiene during the first childbearing cycle. Every person is considered to be spiritually impure before the siring of offspring. This is clearly demonstrated by the burial procedures that are widely practiced for those who die after puberty but before issuing offspring. In this case they are buried with an axe-handle, a rat or corn husk placed at the back as a sign of their spiritual impurity. The purification ceremony which ensures admission into the spirit world is not carried out for them. The first conception is believed to teach the individual self-denial. By sacrificing self interests for the health and welfare of the expected child, the parent learns spiritual or moral hygiene. Once the person is at the stage where behavior and actions are controlled by conscience, he or she has reached spiritual maturity. He or she can now participate in religious ritual. prescribe medicines for other people and attend deliveries. The other four phases become a natural progression to the eternal life. No effort is spared to reach this stage. All health problems are interpreted in medico-religious terms. Thus their diagnosis and treatment require a religiophysical approach. These phases have little relevance for the childbearing cycle and descriptions of these later phases are not included in this paper. The concept of health care In local tradition it is believed that a person’s growth and development are influenced by his or her interaction with the physical, social and spiritual environments. Therefore traditional medicine which is based on these beliefs investigates all the environments for the causes of diseases. Ensuring moral hygiene for the immortal soul is its most important concern. By comparison, western medicine emphasizes physical health and hygiene for the body.

childbirth,

mother

and child

care: Limbabwe

17?

It is for this reason that western and traditional treatments are freely interposed. The western treatments are for the body and the traditional treatments are for the developing mind-soul which will in time achieve eternal life. In local tradition, diseases are transmitted by “mamhepo” (bad airs). It is believed that environmental air contains good and bad eleis environmental air in ments. “Mamhepo” which the quantity of bad elements is greater than that of good elements. Traditional medicine identifies two types of “bad airs” from the three environments that interact with the individual during growth and development. Proper growth and development. good health and prosperity are believed to be sustained when good and bad elements are in balance. This balance is maintained by harmonious and peaceful relationships. These relationships are sustained by the individual’s moral and just conduct. The first type of “bad airs” is associated with natural illnesses or diseases that only affect the body. It causes natural illnesses and is believed to originate from the physical environment. The source of origin is believed to be any natural phenornena such as decaying matter. seasonal and temperature changes of the environment. Bad elements from such sources are believed to cause only such “normal” or minor illnesses such as coughs, colds, transient fevers or diarrheas. They are not viewed with alarm and no spiritual significance is attached to them. In fact they are accepted as a turn in the blood or body physiology. Treatments for health problems of this nature can be prescribed by any knowledgeable person of moral standing in the community. The second type of”bad airs” are associated with “unnatural” or serious illnesses or diseases which originated from supernatural forces or spiritual powers. They affect the body to the extent that the person’s mind-soul and spirit are debilitated: the person’s social existence is upset and his spiritual existence is threatened. These more serious illnesses are related to ancestor spirits in that the sick individual is either immoral and therefore spiritually im-

pure or has transgressed against the spiritual tradition. Ancestors are involved in every aspect of daily life. illnesses from supernatural foccrls are therefore believed to attack only those people of immoral or unhygienic physi4. social and spiritual habits. People of such behavior are believed to loose their ancestor spirit protection: without which their resistance against serious health problems is lowered. Susceptibility to such health problems arises either by having a jinx placed on one or they are associated with immoral or unhygienic physical habits. e.g. illnesses transmitted by promiscuous husbands or wives. Beliefs and behavior during childbearing period

Women are viewed as responsible for fertiiity. nurturing and the social upbringing of their offspring. They are regarded as symbols of the social environment and are thus associated with promotion and maintenance of the individual’s social health and hygiene. Susceptibility to health problems such as infertility; improper nurturing: the loss of a job: sour relationships; accidental injuries are associated with lack of health protection by the social environment, i.e. maternal ancestors. Men are vieyed as responsible for the spiritual or moral upbringing of their offspring. They are regarded as symbols of the spiritual environment and are thus associated with promotion and maintenance of the individual’s spiritual health and hygiene. Susceptibility to health problems that terminate or threaten to terminate the soul’s physical existence before it has matured to the spiritual stage are associated with lack of health protection by the spiritual environment, i.e. paternal ancestors. Use of health systems in pregnancy and childbirth

The bulk of* knowledge that influences the perception of healEh, illness and causes of diseases in general health. mother and child care. is based on the foregoing religio-sociocultural beliefs. /HI J G,vnoecol Obster 23

Most Christianized or westernized people in Zimbabwe experience conflict over the use of some aspects of traditional medicine. This conflict seems to be related to the diagnosis and treatment of serious health problems which usually involve a religio-physical approach. Since in local traditional religions there are no formalized priests, the traditional healer often acts as both priest and healer. This sets him and his practice apart. However, the westernized or Christianized people will consult the traditional midwife and traditional pediatrician without experiencing any conflicting feeling at all. Birth canal relaxants are prescribed by traditional midwives and utilized by all sectors of the society. The “Lippia Javanica” leaf is prescribed by folk pediatricians and used by both traditional and modern people as a home remedy for coughs and colds in children just like any coughsyrup from a pharmacist’s counter. The practices of the traditional midwife and pediatrician are viewed as dealing more with health problems of the body, the physical and social environments. Health problems associated with physiologic changes during pregnancy and labor, and minor coughs and colds in infants, are all regarded as bodily health problems. They, like health problems arising from ecological changes, are accepted as natural processes of life. Delayed labor and delivery are attributed to jinxing potions. These are associated with the social environment. Traditional midwives and pediatricians are thus not viewed as traditional healers but as spiritually-mature people who excel in moral hygiene. Practices during pregnancy

The new bride is expected to conceive and be returned to her parent’s home for the delivery of her first baby within the first year of marriage. Thus. the primigravida is normally at her husband’s home during the first 6 months of pregnancy. The husband is expected to go out of his way to please his wife. Family elders provide physical and emotional support to the young pregnant woman. The women advise her

Pregnancy.

on what they consider to be the appropriate diet for a pregnant woman. In the villages pregnant women are routinely advised to eat some foods in moderation and others as much as they can tolerate. The following are some examples: (1) A variety of green leafy vegetables are encouraged, especially pumpkin leaves which are believed to be easily digestible. (b) Vegetables high in mucin content, like okra, are encouraged because it is believed that they increase laxity of the vaginal mucosa thus facilitating easy delivery. (c) Eating thick porridge made out of rappoko flour is encouraged because it is said to be more nutritious, digestible and thus reduce tendencies of developing heartburn. (d) Fatty foods are, however, to be taken in moderation. They are associated with production of excessive amounts of vernix caseosa in utero. This, in turn, is believed to cause delayed drying and dropping of the baby’s umbilical cord stump after delivery. To reduce formation of excessive vernix caseosa, pregnant women with an appetite for fatty foods are encouraged to chew and swallow juice from the bark of the “mushamba” (livelong or Linnea discolour) tree. In both modem and traditional local societies, it is customary that the father’s sister, great aunt or grandmother prepare the brideto-be for married life. She is told how to physically and socially care for herself, her husband and his family before she leaves her parents home. She is also advised on how to maintain peace of mind especially after conception. In local tradition mental hygiene is very important. It is believed that a woman in anger or in any moral conflict will not deliver normally until her mind is free of unclean or immoral thoughts. It is also believed that emotional disturbances in the mother can produce physical abnormalities in the fetus,

mother

and child

care. Limhahrc-e

2’9

Senior members of the husband’s family observe carefully for the first signs of established pregnancy. In the third trimester, the primigravida is returned to her parent’s home for the “masungiro” (binding or tying) ceremony and delivery of her first baby. “Masungiro” refers to a Shona ceremony that spiritually binds the two families and their ancestors to the couple’s marriage. Of the 144 childbearing women interviewed in the Chikwaka study, only five urban women reported that they had their first child before the “masungiro” rites had been performed. However. in all five cases the husband or boyfriend had to fulfil this rite before he could see the child or claim to be the legal father. After “masungiro” rites the primigravida is handed over to her family for physical, social and spiritual preparations for the delivery. Following the advice of her mother the patient chooses a “grandmother”. from members of the extended family, who is considered to be the most morally hygienic. to act as the midwife. Traditional midwives who do not maintain confidentiality, those whose patients die during labor and delivery. develop complications in the puerperium. are viewed as spiritually impure and therefore morally unhygienic. These gradually drop out of practice because no-one consults them. If a favored “grandmother” is unable to attend to the expectant woman, she chooses a substitute of her choice in consultation with the patient and her mother. The expectant woman and her mother normally call on the preferred midwife with a chicken in hand. The chicken serves as the booking fee. Once the midwife accepts the chicken she is obliged to stay within easy reach of her patient until after delivery. Concepts

Prenatal

childbirth,

of labor

period

The first trimester of pregnancy is expected to be relatively normal. No formal check-up is carried out. Frequent coitus is encouraged for the purpose of topping up the pregnancy.

The patient is not expected to develop complications during labor and delivery if physical. social and spiritual hyiene are maintained. The patient is expected to empty her bladder and bowel, wash the vulva if she can before onset

of strong labor pains. The patient and her husband are expected to maintain moral hygiene by confessing their indiscretions prior to birth of the baby. The midwife is responsible for maintaining moral hygiene of the labor hut and that of her aides. The patient’s mother and her ancestors are responsible for maintaining the social environment pure for normal delic-cry (i.e. all aspects associated with fertility and nurturing). The patient’s father and his ancestors are responsible for maintaining the spiritual environment pure and safe for normal delivery. After a normal first pregnancy, labor and delivery. subsequent childbearing cycles are expected to be normal and do not need the same intense supervision by ancestor spirits. Thereafter the woman may deliver anywhere. If a woman has a stillbirth delivery, she isgiven medicines for *-the uterus that kills”. She is also given medicines to purify her milk for the safety of subsequent pregnancies. The puerperium In western obstetrics the puerperium period is 6 weeks after birth. In local traditions the period lasts until the delivered woman’s back is strong. This may extend up to 3 months after delivery. As soon as the delivered woman can walk steadily, she is given warm medicated or salty water to wash her body, taking special care to wash the inside of her vagina and the vulva. The vagina may also be packed with medicines which are prophylactically prescribed to prevent sepsis. “Jeko” (after pains) are associated with the pressure of the baby on the mother’s abdomen during breast-feeding. Therefore the baby is breast-fed away from the mother’s abdomen for the first few days. For poor lactation the mother is induced to take copious fluids by eating well-salted round nuts which are roasted over a fire. If this fails. medicines referred to as “dururo” (lactation stimulants) are introduced via cicatrix into the breast tissue. Coitus is prohibited for the length of the Iur J Gynaecol Obstet 23

puerperium. This is enforcced by the stigma attached to lochia and menstrual blood. This blood is believed to be impure. A husband who copulates with his wife during the puerperium is believed to suffer from “musana” (backache which is often associated with health problems of the sex organs). A husband who indulges in extra-marital sex during the puerperium commits an immoral act which may cause his child to become ill. Care of newborn

baby

Physical health care of the baby begins when the mother is permitted to breast-feed her baby. During the baby’s rest period, the mother empties her breast of the first colostrum. Colostrum is seen to induce meconium purging which is associated with baby’s abdominal discomfort. The nutritional and immunological values of colostrum are not realized. In local traditions, the infant is born with an inert mid-soul. The infant’s mental health care begins when women first talk to and interact with the newborn baby. Social health care begins when the baby’s birth is announced to (registered with) the family’s spiritual leader as number one, three son or daughter in so and so’s family. Behavioral health care begins with the naming of the child. In local traditions, the meaning of a name symbolically represents behavioral attributes which are likely to become established during growth and development. Giving a child the name “muvimi” (hunter). for example is believe to influence him to grow up to be a hunter. Spiritual health care begins when the father, who symbolizes the child’s spiritual environment, first interacts with his newborn infant after the naming ceremony, after the 8th day postpartum. Prophylactic treatments against a variety of neonatal health problems are administered during these first days of life. The baby who dies before all these levels of health care are established is not spiritually

Pregnancy,

counted. The death is regarded as an abortion. This is why babies born under abnormal circumstances. such as twin deliveries. could be left to die within this period without the family or folk midwife breaching the stringent religious code. Traditional

health workers

The following traditional health practitioners were identified during the study’s investigations: traditional midwife: traditional pediatrician: herbalist; traditional healer; the diviner. By local tradition, health care during pregnancy, childbirth, the puerperium and the neonatal period is provided by: (1) traditional midwives and their assistants. (9) If necessary, more experienced traditional midwives who can handle more complex problems during delivery, such as: rotating baby’s head in cases of persistent occipito-posterior position; performing versions: prescribing “sunungure” (possibly a traditional medicine oxytocic for uterine inertia); retained placenta. (3) Traditional pediatricians who specialize in neonatal problems. Fifteen of the twenty traditional midwives and the five traditional pediatricians interviewed in the Chikwaka study reported that they were taught the trade by a grandmother, mother or great aunt through selection in each case, to continue after them. They all said they loved their work. The remaining five folk midwives reported that they began practicing as traditional midwives after attending to an emergency delivery. One traditional midwife did not like her work, she said it was a dirty job. As a rule in local tradition, only females become traditional midwives. The purpose of providing health care in local traditions is to ensure that iife (the soul) grows and develops to the spirit stage. Therefore the promotion of health, prevention of diseases and their treatment are seen as religious responsibilities which must be carried out by spiritually or morally hygienic people.

childhirrh.

morher and child care. Limhahwe

28

1

Folk pediatrician’s specialization services Specialized pediatric treatment of? C1) “NhowaiChipande” (fontanelle problems): (1) “Gasva” (Buka ascribed to thick and gelatinous cord); (3) “Ndongorongo” (colic ascribed to thin pale cord); (4) “Zuwa” (sun diarrhoea): (5) “Buka” (convulsions nightmares); (6) “Chifumuro” (a variety of prophylactic prescriptions that are believed to protect the child against diagnosed and undiagnosed childhood diseases): (7) “IMurondera” (infants appetite stimulants): (8) “Pahuro” (throat infections scraped and treated - Quinsy). In the Chikwaka study. all traditonal midwives interviewed reported that they diagnose pregnancy by observing: (i) Changes in temperament. At the beginning of pregnancy a woman is believed to become hypersensitive to or less tolerant of irritating situations. (ii) The development of “doma”. that is. the woman becomes easily fatigued: complaints of general malaise, develops cravings for rare foods or picca: intolerance to some smells; experiences frequent vomiting: excessiv-e salivation and may complain of dizziness. (iii) Eight of the 20 folk midwives said. in addition to the above. they also diagnose early pregnancy by looking at changes in the woman’s: (a) teeth. which become bright white; (b) pinna of the ear, which becomes translucent when the woman is standing in bright sunlight: and (c) leg veins, which become prominent. Prenatal examination On a suitable day the traditional midwife or “grandmother” calls her patient into her own or the patient’s mother’s cooking hut for the first formal pregnancy examination. The most important reasons for the visit were: (1) to establish the estimated month of delivery; t 2) to establish and correct unhealthy social relationships before the patient goes into labor: (3) to assess and, if necessary, correct abnormal presentations: (4) to assess adequacy of the obstetric outlet and diagnose for referral or special prescrip-

282 Mitambirwa

tion women with “magodo echirume” (android

The second trimester of pregnancy

~11 midwives interviewed in the Chikwaka study said they diagnose narrow and adequate obstetric outlets by externally fitting a clenched fist between the ischial spines; (5) to mentally prepare the primigravida against low pain threshold. It is feared that an uncooperative patient may damage the baby’s brain at the crowning of the head during delivery; (6) to prescribe “masuwo” (birth canal relaxants). These medicines are of the following types: (a) ingestible types which are believed to increase pelvic joint mobility. These are graded as mild, moderate and strong, depending on how fast or well they produce diuresis and reduce edema of the obstetric pathway. The medicines must be freshly brewed. To ensure safety of the mother and fetus, the midwife drinks some of her prescription before administering it to the patient. The patient drinks the medicines naked and standing up to facilitate observation of abdominal changes. It was reported that some “masuwo” medicines stimulate uterine contractions soon after their ingestion especially where lightening has taken place. (b) Massaging types which are believed to relax vaginal muscles and facilitate adequate stretching of the perineum. It was reported that the “aloe” plant is used extensively for this purpose. “Masuwo” medicines are prescribed for patients during the first pregnancy and during the second and third pregnancies in women who have narrow obstetrical outlets. After taking “masuwo” the patient is advised against copulation. The exercise is believed to counter the laxity achieved by the relaxants. The grandmother is responsible for prenatal teaching of the expectant father. (7) to teach the patient how to recognize true labor; (8) to teach the patient how to care for her nipples and skin. The woman is advised to rub peanut oil over her skin especially around the nipples (to prevent them from cracking) and the stretched skin over the abdomen (to reduce formation of striae gravidarium).

All traditional midwives in the Chikwaka study reported that prompt attention is given to unusual physiological changes during the second trimester of pregnancy. They observe for signs of hyperemesis gravidarum and threatened abortion. In both cases they prescribe remedies for “kutsigisa” (stabilizing) the pregnancy.

pelves).

Int J Gynaecol Obsret 23

Preparations for labor and delivery

Most traditional midwives prepare and store, in advance, their delivery tools in an earthenware pot filled with mealie-meal. The kit usually consists of cord ligatures made from processed sisal or bark fibre and reed blade for cutting the umbilical cord. She also keeps a portshed and Devil’s Thorn leaves for washing hands; a porringer for boiling medicines for the newborn baby. The patient’s mother’s or grandmother’s cooking hut is used for labor and delivery. Until the hut is purified with medicine. about the 8th day postpartum, the family’s cooking is done in a temporary shelter outside. The midwife often has two aides: an elderly woman assistant to support the patient in labor; and a young girl to run errands. On the day of labor they prepare a fire in the hut and brew non-alcoholic sweet ale made from malt flour. This is used as a warm refreshment for the woman in labor. The first stage of labor

The patient is encouraged to take her mind off the pain by continuing to carry out her daily duties until she can bear it no more; or when rupture of membrane occurs; or when she notices the show. Some traditional midwives encourage their patients to push soon after the above happens. This often results in a number of obstetric complications. In women of adequate pelves. however, the complications may not arise because all experienced midwives in the Chikwaka study said they prescribe “delivery fast”, oxytocic medicines as soon as labor is well established. All reported that these medicines are excellent

FregtIanc_v.

for

speeding up labor and delivery. (Many vvestern-trrlin
This stage is identified by descent of the baby. The patient is supported by the aide into a squatting or semi-Fowler’s or semi-sitting position. In truly traditional midwifery. the assistant supported the patient with the aid of a mortar for pounding millet. The patient’s buttocks rested on a reed mat cushioned by Prince of Wales leaves: or on a pressure ring which also protected the baby from maternal fecal contamination during the delivery. A11 traditional midwives in the Chikwaka study said they wash their hands with warm water and Devil Thorn leaves before attending to a delivery. The leaves have a high mucin content which the midwives said helps to reduce trauma of the puerperium tit is also reported in scientific circles that these leaves contain carbolic acid). Except in cases of persistent occipitoall traditional midwives posterior position. interviewed said they do not normally interfere with the mechanism of labor. The infant’s head and shoulders are born spontaneously or with minimum assistance from the midwife. Hence, the emphasis on prenatal teaching against low pain threshold. Complications The midwives reported that the most common causes of delayed labor and delivery are: (a) uterine inertia and persistent occipitoposterior position. The midwives said these are physical health problems which do not need spiritual intercessions. They refer specialist practitioners to perform versions or to prescribe for uterine inertia without addressing ancestor spirits. (b) Jinxing. Associated with labor. this refers to crossing the baby’s obstetric pathway. It is believed that ill-wishers plant jinxing potions which emit bad airs. which cross the obstetric pathway and cause slow descent of the infant during labor.

childhirrh.

mother

and child

care: Zimbabwe

283

This jinxing is viewed as a social health problem which requires social purification of the laboring woman’s environment. For labor to recommence normally. the culprit must confess: remove and bury the jinxing potion: and in fult view of those present. wash hands to spiritually cleanse herself before touching anything in the delivery hut. The third stage of labor The third stage of labor is identified by separation and delivery of the placenta. All traditional midwives in the Chikwaka study reported that the third stage of labor worried them the most. However, because of their rudimentary knowledge of anatomy and physiology their concern is not based on an understanding of postpartum hemorrhage as is the case in western obstetrics. Theirs is based on fear of maternal death due to retained placenta; a complication attributed to lack of moral or spiritual hygiene. The midwives reported that placental separation is identified by the “gush of blood” which must occur within “an accepted time span”. Some said they also observe for lengthening of the cord. The midwives do not cut the umbilical cord until the placenta is delivered. After delivery of the baby, the mother is helped into either the squatting or some sort of knee-chest position for delivery of the placenta. In cases of delayed delivery of the placenta. the midwives reported that they use any of the following measures: (a) massage the uterus to stimulate uterine contractions; (b) give warm “bumhe” to which has been added “sunungure” tpossibly a traditional medicine oxytocic): (c) artificially increase abdominal pressure over the uterus and encourage placental separation by: (i) pressing a wooden spatula over the woman’s tongue to induce gagging: (ii) tickling the back of the throat to induce vomiting: and (iii) administering herbal sneeze powders. td) it was also reported that a minority of traditional midwives sometimes administer salt water to induce vomiting. This vomiting may explain the dehydration seen in some of the postItzr J GJrzaecol

Obsrer

23

284

Mitambirwa

partum admissions to western health centers. A warm pad may also be applied to the patient’s small of the back. Thereafter, any one of the above procedures may be repeated. If all else fails. the patient is referred to a western health centre. The fourth stage of labor After delivery of the placenta the woman is placed on a clean mat. She is asked to cross her legs and thighs tightly to prevent air from entering the rectum and vagina. The uterus is not usually massaged after delivery of the placenta. Instead the patient is given warm medicated “bumhe” which is said to contract and clean the uterus, The patient may eat as soon as she feels up to it. Care of the newborn baby After delivery the baby is placed naked, for observation, on a cloth or blanket-covered mat near the fire until the placenta is delivered. The mouth is wiped with a piece of cloth or freshly picked non-poisonous leaves such as those of “muzhanje” (Uapaca kirkiana). In cases where the infant is limp after delivery, the midwife twirls water in her mouth to regulate the temperature. Then she resuscitates the infant by jetting or spraying the water from her mouth over the baby. A winnowing basket is also used as a cold-shock fan. For infants who show signs of conjuctivitis, the midwife may instill eyedrops made from Devil’s Thorn leaves. In the Chikwaka study, traditional midwives reported that after tying and cutting the umbilical cord they wash the baby and dress the cord stump with any one of the following agents: (i) powders prepared by burning special berries or herbs; (ii) ashes from the cooking place; (iii) “chin’ai” (soot which is reported to have causterizing properties due to the mixture of hydrocarbons in the soft oily house soot); (iv) house rat droppings (reported to contain, among other things, bacteria which speeds up digestion of the cord stump). The baby is then left to rest for a few hours. Full health care for the infant begins after the rest period and this is carried out at the physiInt J Gynaecol

Obstet 23

cal, mental. social. behavioral and spiritual levels of health. During the puerperium period the grandmother or midwife discuss the methods of conception and infant feeding with the young woman. The following are methods of contraception reported by the midwives as discussion topics: (1) Coitus interruptus which was reported as an unreliable method. (2) Continuous breastfeeding was reported as a most popular method. However, it was said before a couple returns to normal sexual activity, the breastfeeding child must be given “murondera” (appetite stimulants). It is believed that sexual intercourse produces watery milk “mukaka usina ruomba” in the breastfeeding women. The watery milk is viewed to be produced quickly in the excitement of the sexual act. It is thus believed to have less cream and nutrition than milk produced over time. The appetite stimulants are intended to increase the child’s intake of the watery milk and avoid a “light weight” baby. The ladies in the village often spot check babies for “light weight” by raising them up into the air. The mothers of “light weight” children are humiliated in front of their peers as a form of chastisement. (3) “Mishonga yekunwa” (oral prescriptions); and (4) “neyekupfeka” (and those for insertion) were reported as effective. However, their use is not popular because they must be prescribed by specialists, who know the antidotes for their contraceptive medicines. Any medicines introduced into the body by ingestion, insertion, injections, etc., are believed to remain there or to cause permanent changes that can only be reversed by taking an antidote. (5) “Mhimvu” (pieces of contraceptive herbs hung on a string around the woman’s waist). It is believed that contraceptive properties contained in the herbs are absorbed as they rub against the skin. It is believed that over time an effective concentration is achieved in the blood stream which protects the woman against conception. Thus, the woman must not remove the string from her waist until she is ready to conceive.

Conclusions

In conclusion, some interesting observations can be made from the foregoing: ( 1) Diagnosis of pregnancy, whilst accurate, is nonetheless more of confirmation than a diagnosis. (2) Prenatal care and examination are generally restricted to the primigravida. Preparations for a successful delivery are elaborate, reassuring to the expectant mother, spiritually and relatively physically hygienic. Reasonable instrument hygiene is exercised. However, this is not based on understanding of the germ theory. (3) The peri-partum complications are ascribed to immoral and amoral reasons rather than an understanding of uterine inertia, or cephalo-pelvic disproportion. dystocia Spiritual uprightness is viewed far more seriously. (4) The relationship of good nutrition in pregnancy and child growth is vaguely understood. There is no apparent visible relationship of modern concepts of nutrition to growth and development. (5) Postnatal care, as in western obstetrics. is divided into neonatal pediatric care and obstetrical care (an interesting base for comparison and obstetric teaching and planning). (6) Fertility control is not an alien concept; however. methods of birth control are at best a set of beliefs reinforced by little known and understood herbal medicines.

(7) Overall obstetrics and pediatric\ in this society are inseparable l‘rom the religion and philosophy ot‘ the local people. The ceremony and ritual involved with every btage ot‘ human life forms part and parcel of the concept 01’ the life ~yclc. its purpose and meaning. To correct obstetric problems arising t‘rom the traditional health system thus requires: (a) proper comprehension of local rnidwiierq, practice?;. the beliefs and the intentions hehind them: (b) eradication of harmful practices bq introducing new or scientific ones built in part upon already existing traditional concepts. i.e. based on what the villager knort~, can understand. cisuake or conceptualize and pructice: (0 facilitating adoption of established practices by traditional midwives through educational sessions which should be given at rural health centers. Bibliography Mutambirucl

J51: Show

tices. Ob\trtric\. Developmenr lkhrd

in Relation

PhD the&

Neubane

London.

Ruth

FL.

University

Zimbardo

Requests for reprints

Harare.

PhD,

of Zim babue,

Zimbabwe

Prac-

of Growth

and

,Medlcine. L’npub-

of Zimbabwe. 1984. in Zula Medicine.

Academic

1977.

F‘or\mun and Company.

Jane Mutambirwa,

Rrlipto-Medical

and Concept,

to Scientik

H: Body and Mind

Prw.

University

Patho+.

Paediatrics

PC:

P\ycholoey

Glenvieu.

and

Illinoi\.

Life. 1970.

Scott.