Women's Health In Tanzania

Managing motherhood managing risk

Fertility and Danger in West Central Tanzania

Motherhood as a Category of Risk

"Mrs. X died in the hospital during labor. The attending physician certified that the death was from hemorrhage due to placenta previa. The consulting obstetrician said that the hemorrhage might not have been fatal if Mrs. X had not been anemic owing to parasitic infection and malnutrition. There was also concern because Mrs. X had only received 500 ml of whole blood, and because she died on the operating table while a Caesarean section was being performed by a physician undergoing specialist training. The hospital administrator noted that Mrs. X had not arrived at the hospital until four hours after the onset of severe bleeding, and that she had several episodes of bleeding during the last month for which she did not seek medical attention. The sociologist observed that Mrs. X was 39 years old, with seven previous pregnancies and five living children. She had never used contraceptives and the last pregnancy was unwanted. In addition, she was poor, illiterate and lived in a rural area"

-World Health Organization, "Maternal Mortality: Helping Women off the Road to Death (emphasis added)

The path to Mrs. X's death, and the interventions that could have prevented it along the way

Safe Motherhood Initiative

In 1986 500,000 women died every year from birth complications and 99% of those deaths were in third world countries

Safe motherhood initiative: Since the mid-1980’s international attention has increasingly focused on the high levels of maternal mortality in the third world

Maternal mortality has decreased greatly since the Safe Motherhood Initiative was enacted

World Health Organization

Commitment - Every Woman Every Child

  • Tanzania will increase health sector spending from 12% to 15% of the national budget by 2015.
  • Tanzania will increase the annual enrollment in health training institutions from 5000 to 10,000, and the graduate output from health training institutions from 3,000 to 7,000; simultaneously improving recruitment, deployment and retention through new and innovative schemes for performance related pay focusing on maternal and child health services.
  • Tanzania will reinforce the implementation of the policy for provision of free reproductive health services and expand pre-payment schemes, increase the contraceptive prevalence rate from 28% to 60%; expand coverage of health facilities; and provide basic and comprehensive Emergency Obstetric and Newborn care.
  • Tanzania will improve referral and communication systems, including radio call communications and mobile technology and will introduce new, innovative, low cost ambulances.
  • Tanzania will increase the proportion of Children fully immunized from 86% to 95%, extend PMTCT to all RMNCH services; and secure 80% coverage of long lasting insecticide treated nets for children under five and pregnant women.
  • Tanzania will aim to increase the proportion of children who are exclusively breast fed from 41% to 80%.
WHO Countdown to 2015 (data from March 2012)

Women who get at least one visit for antenatal care: 87.8%

Births at an institution: 50.2%

C-section births: 4.5%

Contraceptive Prevalence: 34.4%

Culture and tradition

Women and their role in society

In Tanzanian culture, a woman's main job to reproduce and raise children. This is emphasized greatly in society and culture, as much rituals and practices are based around fertility and womanhood. If a woman is infertile, she is thought to be cursed, and this woman will do many things to become fertile, to avoid the common consequence of infertility: husbands leaving.

It is believed that a woman's actions are directly linked to danger in childbirth or infertility. For example, a woman's promiscuity leads to infertility or health problems in unborn and living children. but it is not the same case for men."men do not have much to do with children"

"Mhola" is a true man or woman, meaning they are able to reproduce. Men or women who are unable to reproduce are not "mhola." There is a serious preoccupation with this concept. Women, especially, will go to great lengths to be "mhola," including going to healers and participating in rituals that could be dangerous.

Left-sided Fathers and Right-sided Mothers

  • The left hand is that of the male, it is the "strong" hand that holds the hunter's bow
  • The right hand is that of the female, it is the hand that a mother uses in placing a small child on her back.

These symbols of parenthood represent the individual sides of parenthood, but when each half is put together, they form the whole person. This is the concept of budugu, and is central to Tanzanian culture.

Fatherhood and Motherhood are each valued in their own right and for their collective value

55% of woman interviewed said that they had, at some point in their lives, taken an herbal remedy to either become pregnant, or to ensure their pregnancy was carried to full term.

When a woman becomes a mother, she is then known as the mother of her child. Her name changes to Mama _____. (If her first borns name is Masanja, then her name is now Mama Masanja)

The emphasis placed on motherhood has a direct link to women's health. Women will do many, often dangerous, practices to achieve fertility, as it is considered their central role in society.

The Menstrual Cycle

Women can calculate the timing of their cycle in two ways:

  1. Some look at the position of the moon at the onset of bleeding (west, east, or directly above)
  2. Women who knew how to read, would use a calendar. However, they would note the date that their cycle started, and expect it to begin on the same date the next month. (if it began on the 12th of one month, it should begin on the 12th of the next month)

Women keep their menstrual cloths close by; if another gets ahold of the menstrual cloth, it is believed that they will be able to perform rituals and use sorcery to curse the mother and the unborn children.

"Another woman told me that a person could block a woman's menses, and thus fertility, by stealing a woman's menstrual cloth and burying it in a place where grass wouldn't grow"

Modern and Non-Modern Methods of Conception Prevention

Timing of cycle is noted, but there are different beliefs of the least fertile time. Some believe that the most fertile time was the last day of the woman's cycle, or a few days after because the blood was still "close," so the safest time was halfway through their cycle if they wanted to avoid becoming pregnant (this is actually the most fertile period of a woman's cycle)

Pigi: a picee of root tied on a string and worn around the woman's hips, the number of strings for the number of years of infertility (however, it is believed if the string breaks, the woman is infertile forever)

Modern methods of preventing pregnancy are available at local government clinic, but are not widely used. Only 22.1 percent of women who still experienced menses had ever used a method of oral contraception, and of those, only 30 percent were currently using it.

  • 14.9% said they believed birth control caused health problems
  • 8.7% said they still wanted to get pregnant
  • 8.7% said they didn't want to use it
  • 3.7% said their husbands forbade it
  • 48.1% stated they "just didn't want to use it"

Abortion

Cases of abortion are most prevalent among school age girls

Often, when a young girl is pregnant, she is expelled from the school, resulting in the girl attempting to self-abort or go to an abortion clinic (often far away)

"During the course of my twenty months of residence in Bulangwa, several young girls at the local secondary school attempted abortion."

Cultural Prohibitions During Pregnancy

  • Can't cross river
  • Can't leave husband during pregnancy
  • Can't carry loads if moving to another residence
  • Can't apply mud plaster to walls or floor
  • Can't put stones together for cooking
  • Can't carry stone on head
  • Can't prepare place to beat sorghum/millet
  • Can't go to graveyard
  • Can't leave husband when child is small
  • Must sleep at same level as guest
"In sharp contrast to the Safe Motherhood Initiative's concern with harmful cultural practices that restrict pregnant women's intake of nutritious foods, none of the women I interviewed mentioned food taboos at all."

A wife's argumentativeness is only tolerated during pregnancy. A man will be admonished by family members and neighbors alike if he beats his wife during pregnancy.

prenatal care

"Although many women in Bulangwa place a positive value on fertility and motherhood...pregnancy also appears to be a period of increased stress for women, as evidenced by the negative emotions many admit to feeling while pregnant..."

Prenatal cards

These cards are like mobile hospital records that are used to identify the category of risk in a woman's pregnancy. The clinic nurse updates the card with vital signs, weight of mother, and growth of baby each time the mother visits the clinic. The card also provides a history of previous pregnancies and births and any health problems that she had during her most recent pregnancy.

Without a prenatal card, many women will be turned away from hospitals or clinics. These cards are used for the referral system created by the Safe Motherhood Act.

Referral system

A woman first visits a prenatal clinic, if any problems or risks are noted, she is then referred to a high level of care, and it continues up the ladder until you reach a government hospital. This is written on the prenatal card (and a star is put in the corner to warn illiterate traditional midwives of high risk pregnancy)

Unfortunately, this system had a negative side effect in that this restricted care. If a woman was had a high risk pregnancy, she would be told to go to another, higher level care facility. Lack of transportation methods made this a problem, and if this was expressed, they still would not get care. A good example of this is on page 170, when a young woman miscarried in a marketplace instead of miscarrying safely in the hospital, because she was denied access to the clinic.

"Staffing problems, shortages in supplies and equipment, and problems with transportation were identified as key factors that negatively affected the quality of routine care and referral available to pregnant women"

Biomedical and Non-biomedical forms of prenatal care

Women could give birth at MCH clinics, the division health center, the regional hospital, or a mission hospital

The choice on whether to go outside of the home or village to give birth was related to travel cost, hospital cost, and family suggestion

Many women used both biomedical and non-biomedical forms of prenatal care simultaneously.

Biomedical forms of care are often used for prenatal risks of motherhood i.e. real life-threatening problems that arise when a woman becomes pregnant

Non-biomedical forms of care of often used for prenatal risks to motherhood i.e. conditions that prevented them from carrying their pregnancy successfully to term, miscarriage, and infertility.

Traditional Healer
An unofficial risk associated with biomedical care is harsh treatment some women go through in hospitals and clinics

Childbirth

Kaya nogu, ng'wana nambu

It is easy to marry, but difficult to give birth. -Sukuma proverb

Village Births vs. Hospital Births

When women are ready to give birth, they may go to the midwife in their village or travel to the local hospital. This depends on what they believe or what is available to them.

When giving birth at a government hospital, women were to bring their own supplies including gloves, two vials of ergometrine to prevent hemorrhage, and a syringe. If a woman needed a C-section or stitches, she most provide the necessary supplies. The minimum cost of hospital birth was 2,560 TSH. Women were not required to bring supplies to the mission hospital, but vaginal delivery cost 700 TSH, and a C-section cost 10,000 TSH.

Women's access to money, transportation, and familial support influenced their decision to go to the hospital or stay at home. Some women stated that they stayed at home or went to a healer because nothing went wrong with their previous births, so it would be a waste of money to go to the hospital or clinic.

Many times, the village setting was the less hostile environment, so that is the place where many woman chose to give birth

According to Allen's accounts in Managing Motherhood Managing Risk, women were not treated well in hospitals (p. 193)

"Health workers in Tanzania, many of whom are women, earn very low salaries and work in conditions that are often characterized by a lack of the most basic biomedical supplies...The day-to-day frustrations of working in conditions where they receive low pay and are unable to respond appropriately to obstetric emergencies undoubtedly affects health workers' ability to remain motivated to work, and ultimately, the quality of care that pregnant women receive"

In hospitals, nurses often scolded women if they did not arrive clean, or they arrived without a prenatal card. Women were also in charge of cleaning up after themselves after the birth.

In both settings, women were repeatedly told to remain quiet and calm during child birth to focus on pushing. Women were given a herbal tea to help with certain symptoms of childbirth, to speed up labor, or to even turn the child in the womb. Herbal remedies were also given if it was believed that there was a spiritual risk to the pregnancy.

Remaining stoic during childbirth was highly regarded. Women believe that it is improper to scream out during childbirth, and many believe it could hurt the baby. A few Tanzanian women who did not live in a rural setting stated that being stoic during birth was quite admirable.

"I gave birth like an African woman!"

In both settings, the birth position was the same. Jokingly referred to as the "European way," laying flat on their backs. This is different than how women used to give birth: sitting with their backs against the wall and knees bent halfway to the chest, or "sitting upright on an animal skin, their back against the wall"

While child mortality has greatly decreased, maternal mortality is declining at a much slower rate

female genital mutilation

Female Genital Mutilation (FGM) is illegal in Tanzania

However, it is still a widely practiced tradition, especially in rural areas

Female Genital Mutilation (FGM) or Female circumcision is defined by World Health Organization (WHO) as comprising all procedures involving partial or total removal of the external female genitals organs whether for cultural or other non-therapeutic reasons.

FGM usually occurs between the ages of 4 and 8, but could happen as young as birth, or could be done when you are at the age to marry (15-18)

Worldwide an estimated 130 million girls and women have undergone FGM (Toubia,2000).

Why does it happen?

Source, field survey, 2012

FGM as valued inherited practice

"It is believed that avoiding FGM would lead into curse “laana” from ancestors who embraced it as valuable and necessary practice from time to time in memorial. If a girl did not undergo FGM it was taken as a kind of jinx (“nuksi”) to the girl, her family, clan and the tribe as a whole."

FGM as prerequisite to traditional teaching sessions

"Among the Gogo in Chalinze ward, a girl must undergo FGM in order to attend customs and traditional teaching sessions...Such teachings are believed to increase the girl’s matrimonial opportunities as they prepare her to assume marriage responsibilities."

FGM as means to Transformation into adulthood

"It is believed that a girl who is not yet mutilated is regarded as a child; with childish behavior despite her age and role in society. These girls are regarded immature and can never be married."

FGM as means to prevent Promiscuity

"It is believed that uncircumcised women are impolite and oversexed...It is done to ensure virginity before and fidelity after marriage and or to increase male sexual pleasure."

Physical Effects

Pyschological Effects

"many women who had undergone FGM had experienced fear, submission or inhibition and suppressed feelings of anger, bitterness and betrayal."

"This being the case, efforts to eliminate the practice, have to be supported by whoever values women dignity and their contribution in development. Education provision is recommended as basic mechanism in the elimination of FGM."

"However, the government should make effective enforcement of the Sexual Offence Act, 1998. It should enforce the operation of this law and the law should be seen enforced. Practically the government should be directly involved in the campaigns against FGM and not to leave this to Non-governmental Organizations (NGOs) which work under poor financial position."

Child brides

"Tanzania has one of the highest child marriage prevalence rates in the world. Almost two out of five girls in Tanzania are married before their 18th birthday."

The Law of Marriage Act (1971) allows for boys to marry at 18 and girls to marry at 14, with parental consent.

"In July 2016, the Constitutional Court ruled that marriage under the age of 18 was illegal...The government has one year to update its laws. However, an appeal has since been filed."

"Neither physically nor emotionally ready to become wives and mothers, child brides are at greater risk of experiencing dangerous complications in pregnancy and childbirth, contracting HIV/AIDS and suffering domestic violence. With little access to education and economic opportunities, they and their families are more likely to live in poverty."

conclusion

"insufficient attention has been paid to the context in which poor maternal health outcomes occur. this this inattention, in turn, has led to the implementation of generic maternal health policies and programs that are not always relevant to the complexities and realities of women's everyday lives."

When it comes to the health of women, and maternal mortality, there is more than the biomedical cause of death. There are a number of factors that lead to maternal death, including socioeconomic status, access or willingness to undergo prenatal care, place of birth, transportation, tradition, and education. We have to look at these factors even more so than the biomedical cause of death, as they play a greater role in the future of women's health in Tanzania.

Sources

Allen, D. R. (2004). Managing motherhood, managing risk: fertility and danger in West Central Tanzania. Ann Arbor, MI: Univ. of Michigan Press.

Richard, K., & Buberwa, D. (2016). Cultural Significance and Side Effects of Female Genital Mutilation (FGM) In Central Tanzania: A Case of Gogo Women in Chalinze Ward in Dodoma Region. Imperial Journal of Interdisciplinary Research (IJIR), 2(4), 358-362.

Photo Credits

  • http://www.dailymail.co.uk/femail/article-3279514/Extraordinary-photos-women-s-faces-childbirth-captures-bond-unites-parents-Sweden-Tanzania.html
  • https://broadly.vice.com/en_us/article/ive-named-her-scholastica-photos-of-tanzanias-teen-mothers-and-their-babies
  • http://girltalkhq.com/outgoing-nigerian-president-signs-a-law-banning-female-genital-mutilation/
  • http://www.worldfpa.org/?page_id=7372
Created By
Stephanie Koch
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