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SELF-CARE PRACTICES OF PREGNANT WOMEN: A QUALITATIVE STUDY IN A NIGERIAN RURAL COMMUNITY

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Aniekan Etokidem1* and Benson Obu2

ABSTRACT

Context: Inadequate self-care during pregnancy is a contributor to the poor maternal health indices in Cross River State; including the high maternal mortality ratio of 2,000/100,000 live births.
Objectives: The objectives of the study were to identify self-care practices adopted by women during pregnancy and delivery and to identify barriers to quality self care.
Methods: Focus Group Discussions, Key informant interviews and in-depth interviews were conducted among pregnant women, women of reproductive age and other stakeholders in Biase Local Government Area of Cross River State.
Results: The study revealed inadequate knowledge and practice of self-care during pregnancy. Some pregnant women were unable to recognize early signs of pregnancy while others, especially young unmarried girls, tried to hide the pregnancy. Barriers to effective self-care identified included myths and misconceptions, especially the belief that health-related events during pregnancy are caused by witches and wizards, lack of preparation for pregnancy and abandonment of pregnant women by partners, usually due to unwillingness and/or inability to father the child.
Conclusion: There is need for pre-marital and pre-natal counselling and health education so as to address identified gaps in knowledge and practice and lack of male involvement in maternal healthcare.

Keywords: maternal health, pregnancy, morbidity, mortality, self-care.

INTRODUCTION
Self-care practices refer to decisions and actions that an individual can take to cope with a health problem or to improve health.1 Self-care during pregnancy is necessary both for the would-be-mother and her unborn child. There is a positive correlation between self-care practices during pregnancy and birth outcomes.2 Self-care practices are influenced by myths and misconceptions. Thus, some of the practices women embark upon during pregnancy may not have any clearly defined positive or negative impact while some may be apparently negative and injurious to their health. Ignorance may be another reason why pregnant women do not engage in self-care practices. A related study found that out of the 32 women experiencing a medical problem with their pregnancies, none reported engaging in behaviors to keep healthy.3
Some pregnant women have suboptimal care because of the non-involvement of their partners in their reproductive health. For teenage girls, the situation may be worsened by the fact that the person responsible for the pregnancy may not own up to it.
Pregnant women sometimes obtain psycho-social and emotional care from their mothers and grandmothers.4 Grandmothers also act as guardians of tradition and are often consulted in maternal health issues.5 Women often seek spiritual support during pregnancy, with some of them resorting to places of worship while some also have visitation by people believed to have spiritual powers.6,7
A related research carried out in Addis Ababa, Ethiopia found that 12.4% of pregnant women practiced self medication.8 Issues around geographic and financial accessibility to care may be partly responsible for why pregnant women resort to this practice. A similar study in Nigeria found that 26.8 % of pregnant women studied practiced self-medication.9

Sometimes, women may not even know that they are pregnant and this may make it difficult for them to change their lifestyle to reflect their new status and also initiate self –care activities and processes. In a related study among pregnant women, a gravida 3 para 2 respondent said that:

”To be honest, my periods aren’t regular so I didn’t know how many weeks I was. I can go without periods for 6 months. And because of my periods I suppose it took a while before I knew I was pregnant for definite”.10

In the same study, another respondent expressed her self-care practices this way:

“I’d done everything that I could possibly do myself because….. I knew what you could eat, what you couldn’t eat, this that and other, so I followed everything religiously, took my Pregnacare every single day, made sure I drank plenty, had plenty of rest, so I carried out what I knew, but obviously I’d had no checks to make sure everything was progressing alright, I’d had movement, I noted down when I’d had movement and things like that, so I’d done all I could”.10

A study on physical activity in pregnancy documented the view of one discussant this way:

” It’s not news that you’ve got to eat well and not smoke and not drink and do activity in pregnancy…..I think people are aware and choose to ignore it”.11

Health education given to pregnant women during antenatal care (ANC) can influence their self-care practices. Incidentally, only 46% of 7759 pregnant women in Cross River had at least four government ANC visits.2 This means that 54% of these women missed the opportunity of learning about self-care during the health education sessions of ante-natal care. In the qualitative arm of the study, the researchers found that women wondered why they should go to the health facility for delivery when their mothers never did so.12

1.1 Objectives of the study

1. To identify self-care practices adopted by women during pregnancy and delivery.
2. To identify barriers to quality self-care among pregnant women.

2. Materials and methods

2.1 Study area

This study was conducted in Biase Local Government Area of Cross River State, Nigeria. Biase is one of the 18 LGAs in Cross River State and one of the 7 in the Southern Senatorial district. It is bordered in the north by Yakurr and Abi LGAs, in the south by Akamkpa and Odukpani LGAs and in the west by Abia State. The LGA is divided into ten political units (wards). There is a cottage hospital and 54 primary health care facilities in the LGA.
The people are predominantly farmers while some engage in fishing. Several myths and misconceptions, including belief in the ability of witches and wizards to cause virtually any health problem, is rife in this LGA, just as it is in other parts of the state .
Each ward has at least one traditional birth attendant. There are several churches in the LGA, most of which render one form of care or the other for pregnant women, including delivery services.

2.2 Study instruments

A focus group discussion guide was used to conduct FGDs while an In-depth Interview (IDI) guide was used to conduct IDIs. The guides addressed variables such as knowledge of signs of pregnancy, common health problems faced by pregnant women and their unborn children, outcome of such problems during pregnancy and after delivery, how women take care of their pregnancy and their health from the onset of pregnancy till delivery and thereafter.

2.3 Data collection technique

Focus Group Discussions were conducted with young pregnant women, mothers, young girls of reproductive age, elderly women, men and religious leaders. In-depth interviews were conducted with traditional birth attendants. These discussion sessions took place in Akpet Central in Biase Local Government Area of Cross River State from 28th May to 31st May, 2013. The sessions usually held in the morning between 10.00 am to 12 noon. One FGD session was conducted with each group. Each FGD session lasted between 60 to 90 minutes. The pregnant women group had 8 participants, the young girls group had 8 participants, the elderly women group had 7 participants, the young men group had 11 participants, the traditional rulers (Chiefs) group had 12 participants and the religious leaders group had 11 participants. Each FGD session had a moderator and discussions were tape-recorded after obtaining consent from the members of each group. A note-taker also took notes of the discussions. Probes were used to ginger participants to talk freely and wholesomely about the issues.

2.4 Data analysis

Tape-recorded sessions were transcribed by a professionally trained secretary using word-processing applications. Data obtained from the FGDs were analyzed using content analysis approach. The views expressed by each member of a group were interpreted as representing the group opinion and not specific individuals. Verbatim quotes were reported so as to aid understanding of the opinion of the discussants.

2.5 Ethical clearance

Ethical clearance for this study was granted by the Cross River State Health Research Ethics Committee while informed consent was obtained from the participants.

3.0 Results

Recognition of the signs of pregnancy and pregnancy related health problems.

Considering how pregnant women recognize that they are pregnant, a discussant in the young girls group said that:
The first month or three there will be vomiting. Food will irritate them. They don’t want to eat anything because there will be vomiting. Some eat too much. Some of them spit too much. My neighbor eats too much.

According to one of the traditional rulers:

What I observe in my area is abdominal pain during pregnancy. It will pain the woman so that she goes to the chemist to have some help. When pregnancy is 6 to 8 months, some of these women always have swollen legs and at the same time continue to complain of stomach ache.

The health care providers also assist women of reproductive health to know the signs of pregnancy. In a key informant interview, the Chief Nursing Officer of one of the health facilities said that:

We tell them of increase in size of the tummy (belly) and generally teach them cleanliness and changes to expect as pregnancy grows. We also tell them of frequent urination and allay their fears of such signs. We also talk of signs of labor so that they come immediately they observe any changes.

Concerning health problems in pregnancy, a pregnant discussant said that:

I feel series of headache and sometimes I feel weakness of the body. And sometimes I feel pain around my abdomen and waist; I also have swollen legs.

A traditional ruler narrated problems faced by pregnant women this way:

They have malaria which makes them lose weight and they are not able to carry out their activities, and as a result they become weak.

One religious leader added that:

For pregnancy, one of the popular symptoms include vomiting, malaria attack, much spitting. During pregnancy, my wife sleeps much, her face, body will change, painful nipples, tenderness around the navel and when she wants to deliver, she complains of waist pain, water will be coming out. She quickly gets annoyed and when delivery is approaching the stomach goes down. Many will have swollen legs when it nears her time to deliver. She visits traditional birth attendant who gives her leaves to make her piss out (urinate). I notice that her veins will look black when she wants to deliver.

Food cravings and preferences during pregnancy

Regarding food preferences and cravings by pregnant women, a discussant had this to say:

She likes eating a particular food. If she wants to eat mango and doesn’t see that mango, she will not be satisfied. Like one of my neighbors, if she hears the odor of food, she will not eat again. She will go and buy like biscuit and eat.

Another discussant added that:

Sometimes they select food. The one who used to like garri before will not like but will now like rice. The one who never liked yam before will now like yam. Sometimes you see some signs coming out of their parts; you rush them to the hospital.

A non-pregnant young girl of reproductive age added that:

The first one month to three, there will be vomiting. Food will irritate them. They don’t want to eat anything because they will be vomiting. Some eat too much. Some of them spit (saliva) too much. My neighbor eats too much.

Lack of care for pregnant women

The importance of care for pregnant women and how its absence can lead to maternal morbidity and mortality was emphasized by an elderly female discussant this way:

One of the problems they face is nobody to take care of them. Husbands do not help with house work. Lack of feeding and they don’t have someone to counsel them, give them money and take care of them. To me, they don’t feed well. Sometimes they will die, sometimes the child dies too.

A religious leader pointed this out this way:

Most complaints from women are abandonment from husbands, not giving them money and neglecting them. They are malnourished because of poor feeding. Pregnant women face a lot of problems caused by their husbands. Most of them, when they see a beautiful girl outside, they will abandon their wives and be taking care of that one. And because of that, because of much thinking, their blood pressure will rise.

Another discussant corroborated the above this way:

When a child has carried pregnancy, the father will tell her to go and meet the person who caused it. Even though they might go and meet the boyfriend, he might say he is not the one who has the pregnancy. The father will say I am not interested about the child .The mother now will carry the responsibility; let me say the grandmother will now carry the responsibility of that child.

Lack of preparation for pregnancy

From the elderly women’s group came the observation that:

Some of them get into pregnancy without preparation. No money for good food because of poor family. This makes them have swollen legs and malaria in pregnancy. Some of them are not using nets so they have mosquito bites. Some of them do not have good water to drink or even food to eat.

The opinion of an elderly male discussant was that:

The generation has changed. The present generation is not obedient to parents. They are wayward. They don’t take things serious. Some of them when they are pregnant they use wide belt to grip the body so that the body will not expand, so that you will not notice that there is a change in the body. They hide things. That is why most of them grow pale, some also attempt to abort.

Methods used by women to take care of themselves during pregnancy and after delivery.

Patronage of traditional and faith-based care.
Not many participants agreed on the use of traditional methods to take care of their pregnancy. However, giving birth at home was common and was mentioned by all the groups irrespective of whether pregnant women registered at the health facility or not. Registering at the health facility was, in most cases, an action taken to appease the nurses at the primary health centres. Home delivery was preferred in most cases due to factors like distance to the health centre, preference of the woman, labor occurring at night and lack of funds to patronize the health centre.
While all agreed that there are advantages of home delivery, participants did not specifically mention such advantages. One major disadvantage of home delivery was mentioned namely, the risk of tetanus and failure to immunize the baby against childhood killer diseases after birth. All participants agreed that home delivery should be discouraged and women should be encouraged to go to the health center for ante-natal care and delivery.
All participants agreed that they attend various churches and fasted during pregnancy. Some women delivered their babies in the church because of a strong faith that prayers offered there would help them to have successful deliveries free from spiritual attacks. Participants laid emphasis on fear of attack by evil ones in their communities. This was given as one of the main reasons for patronizing faith-based services.

Some pregnant young girls even resort to taking herbs, as narrated by one of the discussants:

When they get pregnant, they will go and tell their boyfriends who would not advise them to go to the health center but to take herbs. That if they take herbs the pregnancies will be terminated.

Another recurrent reason for patronizing church-based services is a history of infertility. One discussant put it this way:

By virtue of the fact that some of these women were infertile and when they finally get pregnant after prayer sessions, they felt compelled to continue to patronize the church during pregnancy, during delivery and after child birth.

Recognition of onset of labour

Various groups presented their views about likely onset of labor:

A pregnant woman said that:
The number one na (is) waist pain. From there I go see water. From there you will hear (feel) pains and they rush you to hospital. Sir, sometimes, you will be feeling sleepy but at the appropriate time you will wake up. And sometimes a white thing will be coming out of your body. Sometimes ”oruk ” (placenta) will break and pour out like water.

4.0 Discussion
The importance of male involvement in their partner’s reproductive health was brought to the fore in this study. The participants were worried that men do not usually give their partners the needed support when they are pregnant. They felt partners should assist with some domestic chores during pregnancy. This may be difficult to achieve because most Nigerian societies are patriarchal in nature.13 The belief here is that women are supposed to be subservient to men and should handle all the domestic chores while men source for money and other means of livelihood. Asking and or expecting men to assist with domestic chores may be regarded as capable of tilting the power equation in favour of women. Sometimes, if a woman insists on this, it could lead to violence against her which may lead to premature labor or miscarriage. This scenario has been documented by other studies.14,15 In patriarchal settings, the decision–making power resides with the men, even in matters concerning the health of women. Sometimes, these men may display attitudes and behavior that become detrimental to the health of their partners, including not allowing them to utilize health services. This has been corroborated by some other studies.16,17 In a related study, it was found that husband’s refusal was one of the reasons why 15.5 % of Nigerian women studied did not utilize maternal and child health services.18 In another study in Northern Nigeria, it was found that 16.4% of urban respondents and 21.2 % of rural respondents mentioned husband’s refusal as the reason for non-utilization of maternal and child health care services.19

Some of the respondents pointed out that sometimes pregnant women are abandoned by their partners. This problem was commoner among young pregnant unmarried girls. Abandonment during pregnancy could lead to some unfavorable outcomes for both the pregnant woman and her unborn child. Lack of care during pregnancy has been identified as the single most important cause of maternal mortality, especially in developing countries.20,21 Abandonment is a global phenomenon. It happens in the developed countries just as it does in developing countries. Concerned about this, the President of the United States of America said that:
Let’s admit to ourselves that there are a lot of men out there that need to stop acting like boys; who need to realize that responsibility does not end at conception; who need to know that what makes you a man is not the ability to have a child but the courage to raise a child.22
The participants in this study laid emphasis on proper feeding during pregnancy. The World Health Organization had earlier noted that inadequate nutrition during pregnancy is an even more marked problem among youths in developing countries.23 Discussants did not seem to engage in physical exercise. This could be because the study area is an agrarian community where women trek long distances to and from farms, even when they are pregnant. Walking and working in the farm may therefore be seen as a normal activity and not necessarily as a form of self care. An earlier study involving 100 women found that more than 50% of them reported activities to keep healthy. Such activities included walking or jogging. Forty-eight percent of them reported changing their diets while 25 % reported working out, exercising, and/or meditating. The report added that of the 32 % of study participants experiencing a medical problem during their pregnancies, none reported engaging in behaviors to keep healthy.3

One elderly discussant disclosed how young pregnant girls try to conceal their pregnancy by tying belt around their abdomen. A similar study documented that pregnant young women may shun disclosure of pregnancy for fear of stigma and parental discovery. In the author’s opinion, these actions may delay interventions to help the pregnant women to initiate self-care practices.2 This is in line with an earlier observation by the WHO that:

Pregnant youths are not aware of danger signs of pregnancy complications. They are ashamed or afraid to seek care, not seeking care or delaying seeking care in the presence of danger signs results in maternal mortality due to complications of pregnancy.23

5.0 Conclusion
There are gaps in both the knowledge and practice of self-care within the community as reported in the different FGDs. Lack of male involvement in maternal health care was a key barrier to self-care and manifests in various forms in this community, including denial of responsibility for pregnancy and outright abandonment of the pregnant woman. These should be addressed through proper counseling and health education.

Conflict of Interests
The authors declare that there is no conflict of interests regarding the publication of this paper.

Acknowledgment
This project is supported by Grand Challenges Canada. Grand Challenges Canada is funded by the Government of Canada and is dedicated to supporting Bold Ideas with Big Impact®.

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