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Medical Pluralism and Utilization of Maternity Health Care by Muslim Women in Mombasa, Kenya

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MEDICAL PLURALISM AND UTILIZATIO N OF MATERNITY HEALTH CARE SERVICES BY MUSLIM WOMEN IN MOMBASA, KENYA By FATMA ALI SOUD A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2005

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Copyright 2005 by Fatma Ali Soud

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This document is dedicated to my parents.

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iv ACKNOWLEDGMENTS This research would not have been possi ble without the help of many people. I would like to thank Dr. Abdalla Kibwana who was my first listener and consultant while writing the proposal and questioning th e feasibility of this study. I owe a huge debt to the 300 women I inte rviewed and to the many others who took time to answer my questions. I was invited in to womens lives and entrusted with very personal and intimate information. I owe great gratitude to Sister Asya Ahmed who opened her home and birthing cen ter and gave me a lot of her time to explain all the social and cultural changes that had taken place in Mombasa. In addition, she took time to re-introduce me to the many physicians, nur ses (especially Sister Rumani Ahmed and Mura Thabit), to the birth attendants Bi Riziki, and Amina AbdulGhania. To Dr. Khadija Shikeli for allowing me entrance into Coast General Hospital. To all the administrative staff and nurse s of MEWA, Sayyida Fatima a nd Al-Farouk hospitals who took time to answer my questions. My sincerest gratitude to Dr. Russell Be rnard for his faith in me, his critical counsel in research design, methods, editi ng and advice. I feel honored to have grown academically under his tutelage. A very special acknowledgement to my committee members, Drs. James Stansbury, Elizabeth Guillette, and Jeffrey Harman. Thank you for your intellectual inspiration and professiona lism. I had the privilege of guidance from other professors who I would like to thank, Drs. Brian du Toit, Michael Chege, Leslie Sue Lieberman, Sharleen Simp son and Maria Grosz-Ngate.

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v To my fellow student supporters, particul arly the dissertation writing group, Roos Willems, Antoinette Jackson, Elli Sugita and Alex Rodlach, thank you for tirelessly reading, editing and providing input as the di ssertation progressed. Speci al thanks to Alex for his friendship, support and encouragement, and for listening as the dissertation took many forms until it was written. Deepest appreciation to my family in Mombasa, Faiza and Abdul Abdulbassit and Aisha who invited my sons and me to live with them during fieldwork. To my sisters Sabrina, Umi and Nasra for their love and enc ouragement. Last but not least to my sons, Abraham and Adam Wilcox for their love a nd support and their ab ility to keep me grounded.

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vi TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES.............................................................................................................ix LIST OF FIGURES.............................................................................................................x ACRONYMS.....................................................................................................................xi GLOSSARY.....................................................................................................................xi i ABSTRACT.....................................................................................................................xi ii CHAPTER 1 LITERATURE REVIEW.............................................................................................1 Introduction................................................................................................................... 1 Theoretical Overview...................................................................................................6 Theoretical Models in Health Care Seeking Behavior..........................................6 Mother-to-child-transmission (MTCT) of HIV.....................................................8 Prenatal care services...................................................................................10 What is adequate utiliza tion of prenatal care?.............................................11 Utilization and access of pr enatal care services...........................................12 HIV positive women and the utilization of health care................................15 2 MOMBASA THE RESEARCH AREA..................................................................18 Geography...................................................................................................................18 History: The Visitors and Administrators...................................................................19 The Coastal People Waswahili.........................................................................22 What Occupies Womens Time in Mombasa? Society and Culture................24 3 MEDICAL PLURALISM IN MOMBASA................................................................30 Introduction.................................................................................................................30 Biomedical Health Care..............................................................................................31 Traditional/ Folk Medicine..................................................................................36

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vii Islamic Healers....................................................................................................40 The Popular/ Lay Sector......................................................................................43 4 METHODS OF DATA COLLECTION.....................................................................45 Introduction.................................................................................................................45 Research Design and Objectives................................................................................45 Native Ethnography.............................................................................................47 Sampling Design.................................................................................................50 Data Collection....................................................................................................52 The Research sites........................................................................................57 Statistical methods........................................................................................66 5 RESULTS FROM THE DATA ANALYSIS.............................................................67 Introduction.................................................................................................................67 Analysis......................................................................................................................6 7 Section A Socio Demographic Characteristics.................................................68 Section B Household Characteristics...............................................................72 Section C Knowledge of Mother-t o-Child HIV Transmission (MTCT)..........77 Obstetrical Characteristics...................................................................................79 Section D Utilization of Mate rnity Health Care Services.................................80 Choice of a childbirth delivery center..........................................................81 Reasons for using a facility for prenatal care or childbirth..........................82 6 ETHNOGRAPHY OF PREGNANCY AND CHILDBIRTH....................................87 Introduction.................................................................................................................87 Menstruation and Puberty Rites Lessons On How to Safeguard Fertility...............87 Infertility..............................................................................................................91 Pregnancy Loss....................................................................................................95 Perceptions of pregnancy.............................................................................96 Prohibitions in pregnancy.............................................................................99 Illnesses in Pregnancy.......................................................................................100 Childbirth...................................................................................................109 Postpartum period ( Arubaini ).....................................................................113 7 SUMMARY AND CONCLUSION.........................................................................118 Introduction...............................................................................................................118 Demographic and Obstetrical Determinants of Health Care....................................119 Household Characteristics and the Domestic Economy....................................123 Local and State Political Economy and Health Care.........................................124 Culture and Womens Health Beliefs................................................................126

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viii APPENDIX A DEMOGRAPHIC CHARACTERISTICS................................................................129 B QUESTIONNAIRE..................................................................................................145 C CODING FOR QUESTIONNAIRE.........................................................................149 LIST OF REFERENCES.................................................................................................158 BIOGRAPHICAL SKETCH...........................................................................................175

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ix LIST OF TABLES Table page 4-1 Interview sites..........................................................................................................52 A-1 Section A Demographic characteristics...............................................................136 A-2 Section B Household characteristics....................................................................138 A-3 Section C Knowledge of moth er-to-childHIV transmission.............................140 A-4 Use of maternity health care...................................................................................141 A-5 Logistic regression model results of the determinants of using prenatal care....143 A-6 Logistic regression model odds of choos ing of a birthing facility as reported by respondents........................................................................................................144 E-1 Coding for Questionnaire.......................................................................................149

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x LIST OF FIGURES Figure page 2-1 Map of Kenya situating Mombasa.......................................................................18 4-1 Data collection sites................................................................................................51 A-1 Percentage of respondents by ethnicity..................................................................129 A-2 Respondents' level of secular education................................................................130 A-3 Respondents' knowledge about mo ther-to-child HIV transmission......................131 A Month biomedical prenatal care started................................................................133 A Respondents' number and frequency of prenatal care visits.................................134 A Percentage of respondents choice of birthing facilities........................................135

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xi ACRONYMS AIDS Acquired immuno-deficiency syndrome HIV Human immunodeficiency virus MCH Maternal child health MOH Ministry of Health MTCT Mother-to-child transmission NGO Non-government organization TBA Traditional birth attendant STI Sexual transmitted infections UNAIDS United Nations AIDS organization UNFPA United Nations Population Fund UNICEF United Nations Childrens Fund WHO World Health Organization

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xii GLOSSARY Swahili Culture of the peopl e of East African coast fr om Mogadishu (Somalia) to Southern Mozambique. Mswahili The person (plural Waswahili or the people) Kiswahili Language used by the Waswahili Kenya shilling (Ksh.) Money used in Kenya th e exchange rate was Ksh. 75-80 to the dollar. Minimal wage ranged between Ksh. 8,000 to 20, 000. Kanga/ Leso A rectangular pie ce of colorful cotton cloth, approximately three by one feet with multi-purpose use, worn in pairs.

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xiii Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy MEDICAL PLURALISM AND UTILIZATION OF MATERNITY HEALTH CARE SERVICES BY MUSLIM WOMEN IN MOMBASA, KENYA By Fatma Ali Soud May 2005 Chair: H. Russell Bernard Major Department: Anthropology This is a study of health-seeking be havior of pregnant Muslim women in Mombasa, Kenya. Early initiati on and attendance of prenat al care has been shown to result in positive pregnancy outcomes. In addition, birth delivery assistance from a trained and well-equipped provider is nece ssary to reduce maternal morbidity and mortality. Kenya, among other countries in Africa ha s a high maternal mortality rate. The major direct causes of mortality are hemorrhag e, sepsis and hypertensive diseases of pregnancy. Malaria, anemia, tuberculosis and HIV/AIDS as well weaken the immune system and add to the toll of death during childbirth. Due to the HIV/AIDS epidemic, Mombasa has an increasing rate of mother-t o-child transmission (MTCT). In this study, womens knowledge of MTCT is assessed. To address these above issues, Kenya de veloped a Safe Motherhood Initiative in 1987. This initiative was to identify poverty reduction strategies among women, improve

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xiv reproductive health and assure child survival. The research reported here adds to the studies of the Safe Motherhood Initiative from the womens perspective. I believe that many of the findings of the research reported here can apply to urban areas across Kenya and, indeed elsewhere in urban Africa where medical pluralism is the norm. I investigated the available maternal h ealth care services and how, when and why women used or did not use them. I used participant observation followed by and a questionnaire to collect data from 265 Mus lim women. Logistic regression techniques are used to estimate models of prenatal care use and choice of a birthing facility. Women were interviewed during the postpartum period, while in the hospital, at home and while attending the sixth week check-up. The result s demonstrate the comp lexities of womens lives and the difficulties they face in accessing maternity health care. Their reasons for not getting the care they need include cost, di stance, lack of competence of health care providers, and frequent shorta ges of essential equipment a nd supplies to provide basic essential obstetrical care. In addition, their beliefs, knowle dge and attitudes about the efficacy of health care services and the curab ility of their condition affect their healthseeking behavior.

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1 CHAPTER 1 LITERATURE REVIEW Introduction This is a study of health-seeking behavior of pregnant Muslim women in Mombasa, Kenya. Mombasa has an increasing rate of mother-to-child HIV transmission and a high maternal morbidity and mortality. HIV-positiv e women transmit the virus to their infants during pregnancy, during childbirth and while breastfeeding. HIV positive children fail to thrive and have delayed motor development, with deceleration in mental health. These children have a poor prognosis. Their health dete riorates at a faster rate due to AIDS, and mortality is hardly past five years of age (Butlerys and Lepage 1998). In 2001 Kenya had 220,000 cases of pediatric HIV infection from mother-to-child transmission (UNAIDS/WHO Epidemiological Fact Sheets 2002). Kenya has a high maternal mortality. In 2001 it was estimated at 590 deaths per 100,000 births, and this is likely to be an unde restimate since many maternal deaths are not reported. The director of medical servic es in Kenya estimates that from 3300 to 6000 Kenyan women die each year of pregnancy rela ted causes (Ministry of Health 1997). The major direct causes of mortality are hemorrhag e, sepsis, and hypertensive diseases of pregnancy. Malaria, anemia, tuberculosis a nd HIV/AIDS weaken the immune system and add to the toll of death during childbirth. To address these problems, Kenya developed a Safe Motherhood Initiative in 1987. This ini tiative was to identify poverty reduction strategies among women, improve reproductive health and assure child survival. The Safe Motherhood Initiative was followed by a National Reproductive Health Strategy

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2 covering the period 1997-2010. The strategy requir ed all districts and provinces to assess the causes of maternal and perinatal morbid ity and mortality (Re public of Kenya 2001). Pilot studies have been conducted across Ke nya to assess the results of these safe motherhood programs (Trangsrud and Thairu 1998) Findings reported here adds to these studies of the Safe Motherhood Initiative. I believe that many of the findings of the research reported here apply to urban areas across Kenya and, indeed, elsewhere in urban Africa where medical pluralism is the norm. This study was initially set to interv iew HIV-positive women, however when I arrived in Mombasa, I was informed by clinicians that this would be difficult since most of the women are not tested, and if tested women do not return for results. Previous studies explain that women do not return for results due to fear of knowledge of an HIV positive status. Another obstacle was women wh o knew that they were HIV-positive did not want to reveal their st atus due to stigma. Although I questioned if a respondent was tested for HIV, I did not inquire whether one is positive or negative. Knowledge of testing and counseling for HIV is an importa nt component in maternity health care assessment. I re-formulated the hypotheses as follows: 1. Muslim women who have strong Muslim beliefs will go to Islamic institutions and healers compared to wome n without similar beliefs; 2. Women who have knowledge about MTCT will seek more adequate maternity health care than will women without similar knowledge; 3. Women who develop pregnancy related i llnesses or complications will seek Islamic healers compared to women without complications.

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3 To explore these above issues, I investigat ed the available mate rnal health care services and how, when and why women used or did not use them. I used participant observation followed by a questionnaire to co llect data from 265 Muslim women in Mombasa, Kenya. Prenatal care services and parturition in a well-run biomedical facility would improve matern al and child health. Howeve r, although most women do not deliver at home, the facilities that they do use do not provide the kind of care that can reduce mother-to-child transmission of HIV. The results demonstrate the complexities of womens lives and the difficulties they face in accessing maternity health care. In relation to the hypotheses, women who had economic means independent of their spouses or family had better access to health care than women who did not irrespective of relig ious beliefs or edu cational status. Women whose economic status was dependent on s pouses, partners, and family members had varied reasons for lack of or poor access to adequate maternity health care. Their reasons for not getting the care they need include co st, distance, lack of competence of health care providers, frequent shorta ges of essential equipment a nd supplies to provide basic essential obstetrical care. In addition, their beliefs, knowle dge and attitudes about the efficacy of health care services and the cura bility of their condition affect their helpseeking behavior. In this chapter, I explain the differe nt theoretical mode ls used by medical anthropologists in analyzing non-Western he alth care decision-making processes and behavior. Kleinmans (1978, 1980) explanator y model is appropriate for this study, it incorporates the individuals cultural response to illness a nd treatment. Furthermore, the model refers to the patients a nd familys conceptions of the na ture of a particular illness

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4 episode, its causes and effects, expected a nd /or desired treatment and apprehensions about the outcome In this chapter, I also explain the thr ee routes through which a mother can transmit HIV to her infant, and the preventive and curative methods to decrease or avoid transmission. I also discuss the importance of prenatal care to illustrate what women should be receiving when they get efficient care. From my personal experience as an obstetric nurse, the expectations developed in the United States about what constitutes adequate prenatal care are unrealistic for Momb asa. I present below some of the debate on the adequate number of prenatal care visits I also review the literature on the use of prenatal care services by women with and without HIV infection and compare it with the results from Mombasa. Chapter 2 outlines the geography and history of Mombasa and offers a brief overview of Muslim womens life there. Momb asa has 750 years of recorded history and it is unique on the African continent. The towns cultural and ethnic mixture comprises the local Bantu with Arab, Indian, Portuguese Chinese and British sojourners, some of whom remained in Mombasa to this day. If a society or culture does not develop procedures for healing and curing, it does not exist, says Rush (1996:138) and indeed, Mombasas fluid and plural medical system, developed from its turbulent history, as I explain in Chapter 3. Chapter 3 outlines the medical pluralism practiced in Mombasa. Kleinmans (1978, 1980) explanatory model divides medical plur alism into three sections: biomedicine, traditional medicine, and the lay sector. Isla mic health practices are found in all three sectors. In Mombasa, biomedicine is resp ected by Muslims when treatment is required

PAGE 19

5 for outbreaks of diseases such as typhoid. However, when the agent for an illness is suspected to be supernatural, Muslims in Mo mbasa seek other means of healing. In this way, they are similar to Christian Indian s in Latin America (Crandon, 1986), Hindus in India (Subedi 1989) and Buddhists in Thaila nd (Golomb 1988, Techastraisak and Gesler 1989). The dissatisfaction of one therapeutic syst em to heal or cure leads users to try others until a remedy is achieved. Chapter 4 explains the methods used in th is research. I presen t the research design and objectives, the advantage and disadvant ages of native eth nography. In addition, I illustrate the areas and methods of da ta collection and the sampling design. Chapter 5 presents the major results from analysis of the 265 questionnaires. The individual respondents questionnaires provided information on the following: demography, household characteristics, knowle dge of mother-to-child HIV transmission and use of maternity health care services. L ogistic regression models the use of various prenatal and natal health care options The ethnography of pregnancy, childbirth and postpartum is presented in chapter 6. I have included womens concerns of sec ondary infertility and pregnancy loss and the herbal and ritual prohibitions and treatment to ensure fertility. Furthermore, I incorporate illnesses that women perceive as risks for a pregnancy and the plural methods used to treat these conditions. I finally narrate my experience of observing childbirth in a homebirthing center. In Chapter 7, I present the summary and conclusion using cultural materialism as a theoretical tool to evaluate the different components that impede or assist womens access to maternity health care. I divide th ese varied factors into the format of

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6 infrastructure (demography, occupation, and obstetrical characteristics), structure (education, domestic and politic al economy) and superstructure (values and beliefs). This model takes into account that there is a relationship between all of these above elements when women seek health care. The concept of reproductive health is a basic human right and any of the above factor/s can help or infringe on this right. Theoretical Overview Theoretical Models in Health Care Seeking Behavior Medical anthropologists have offered five different frameworks for analyzing decision-making about health car e in non-Western societies. These are the determinant, process, mental, systems and critical models. Although these models may provide overlapping, sometimes contradictory e xplanations of similar phenomena, (Ryan 1995:7) no single framework appears adequate for explaining a groups health-seeking behavior. The determinant model attempts to account for intraand interc ultural variation in health-seeking behaviors by examining the characteristics of illnesses, patients, caretakers, households, communities and health care services, as well as the individuals actions and willingness to seek care (Mechanic 1969, Colson 1971, McKinley 1973, Foster and Kemper 1973, Fabrega and Manni ng 1979 and Stoekle et al. 1963). Friedson (1960), Suchman (1964), Chrisman and Mare tzki (1982), Igun (1979), and Young (1981) emphasize that decision making about health ca re is a process rather than simply a determined outcome. The process begins with awareness of an illness, followed by diagnosis, selection among alte rnative therapies, and evalua tion of the therapy. This can lead to new choices and re-evaluation of outcomes. Nyamongo (1998) and Mbeh (2000)

PAGE 21

7 found the process model to have more predic tive power in assessing response to infant diarrhea and malaria respectively. Frackenberg and Leeson (1976), Feierman (1981), and Young (1981) describe the systems model as the impact of social forces on the search for health care. This model according to Janzen (1978) requires two levels of analysis, one at the micro level (incorporating percep tions about an illness, the prevalen ce of the illness, and efforts to diagnose, prevent, and cure an illness) and one at the macro level (incorporating information about large scale social entitie s such as health institutions, economic and political systems that dictate ac cess to health care. Janzen ( 1978) points out that, in most non-Western societies, the reaction to illne ss involves a therapy management group comprising the friends, family and others in th e social network of th e ailing individual. McKinlay (1973:275) adds that the fam ily, its kinship and friendship networks, influence the manner in which individuals de fine and act (or fail to act) upon symptoms of life crisis. Kleinman (1978, 1980), Cominsky (1982), MacCormack (1982) and Good (1986) formulated the mental models approach to health care seeking. This model focuses on how people understand and experien ce their illness and that of others around them. This understanding is, of course, a function of lo cal culture. Kleinmans (1978:86) proposes a theory using the explanatory model (EM) to de scribe illnesses in different sectors of the health system. For each illness, according to the EM approach, there is a set of beliefs about its etiology, onset of symptoms, pa thophysiology, development, severity, and treatment, as well as about appropriate roles for those afflicted. In addition, the EM approach examines macro-leve l or external factors, such as the political, economic,

PAGE 22

8 social, historical and environmental determinan ts in health care seeking behavior. Singer (1990) has criticized Kleinmans use of th e EM approach and ignoring power relations between social groups and between classes. I take this critique into consideration in analyzing the data reported here. The EM a pproach, in theory, provides a way to make cross-cultural comparisons of health-seek ing behavior. Unfortunately, while many scholars have done EM studies, systematic comparison for commonalities across cultures has not yet been achieved. Indeed, I offer the research reported here as a contribution to EM research, but leave for later the systematic comparison of models for seeking prenatal and perinatal care. The critical approach in medical an thropology focuses on how political and economic forces, including the exercise of pow er are used in shaping health, disease, illness experience and health care (Singer a nd Baer 1995:5). This model is holistic, historical and immediately concerned with onthe-ground features of social life, social relations and social knowledge, as well as with culturally constituted systems of meaning (ibid: 81; see also Morgan 1987, Singer 1986, 1990, Singer et al. 1992). The critical model focuses explicitly on macro-level forces to explain behavior rather than on the individual, though the ethnogr aphic data on which critical analyses are based are often individual-level narrativ es (Scheper-Hughes 1992). Mother-to-child-transmission (MTCT) of HIV MTCT of HIV-1 can occur before, during or after birth. The contribution of each of these routes has not been well identified, but it is estimated that twothirds of potential exposure occurs in utero and during birt h while one-third occurs post-natally. Understanding the risk of infection from thes e different routes has been important in public health for the development of appr opriate interventions. According to Newell

PAGE 23

9 (1998), HIV can infect the placenta at all stag es of pregnancy, and in fected placental cells may be passed to the fetus during childbirth. She concurs that when the amniotic sac is intact, transmission may occur from the placen ta to the fetus in fetoplacental circulation. Studies to support intrauterine transmission have detected the virus from fetal material as early as 12 weeks gestat ion, the intrauterine onset of symptomatic HIV disease, and the identification of HIV in am niotic fluid (Newell 1998:831 ). Infants have tested HIV positive within days of birth, with some infections progressing rapidly, suggesting intrauterine transmission (ibid). HIV transmission during labor and delivery o ccurs in two ways. One is from direct contact of the infant with infectious matern al blood and genital secretions during passage through the birth canal. The other is through ascending infections from the vagina or cervix to the fetal membranes and amniotic fluid through absorption in the infants digestive tract. In either case, cesarean section is appropriate for prevention, with immediate suctioning of oral and nasal secreti ons of the infant. The presence of HIV has been identified in the birth canal, with higher levels in pregnant th an in non-pregnant women. Trials to assess reduc tion during delivery by antisep tic cleansing of the birth canal have been conducted in Malawi (B iggar et al.1996), but results showed no significant impact on HIV transmission rates, ex cept when membranes were ruptured for more than four hours before delivery. Studies also suggest a reduc tion in the rate of MTCT with the use of zidovudine (AZT) in pr egnancy and at the time of delivery, though the drug has little effect on the serostatus of the mother. AZT during pregnancy and delivery has become the standard treatm ent in developed countries, producing a transmission rate of fewer than 8% in re gimen-compliant women. This is still not an

PAGE 24

10 option in most of sub-Saharan Africa because of the cost of AZT and other antiretrovirals. A single dose of nevirapine, how ever, given to the mother before she goes into labor, and a single dose given to the ba by within 72 hours of birth, has proven a cost effective treatment to reduce MTCT in deve loping countries (Strin ger et al. 2000), with trials in Uganda (Guay et al. 1999) and in Za mbia (Marseille et al 1998). Other studies done to improve care during delivery (Taha et al. 1997 and Gaillard et al. 2000) have examined possible interventions to reduce MTCT by antiseptic cleansing of the birth canal before parturition. In the postnatal period, breas tfeeding has been associat ed with increased MTCT. The rates are higher in women who are newly infected compared to women with stable infection. Present studies are not clear conc erning the possibility of increased HIV in colostrum. Mixed feeding practi ces also increases risk of in fection, due to damage of the infants intestinal tract from the early in troduction of other foods. Some infants who initially test negative at birth become inf ected at 3-6 months, and in the developed countries, women on postnatal HIV thera py are discouraged from breastfeeding (UNAIDS 1998). Most studies done in Kenya have concentr ated on voluntary counseling and testing for HIV (Cartoux et al. 1996, Vollmer et al 1999 and Sweat et al. 2000) specifically to evaluate the acceptability and cost of testing. Prenatal care services The proper use of prenatal care services results in positive pregnancy outcomes by reducing the risk of maternal and infant mo rbidity and mortality. Health care centers offering prenatal care provide an informal ri sk assessment based on clinical judgment to

PAGE 25

11 guide the providers appropriate monitori ng and possible interventions during the pregnancy (Aday and Andersen (1975). Various factors ((previous medical and obs tetrical history, screening laboratory results, and intrapartum events that predict perinatal morbidity and mortality) are assigned risk scores which, together, produ ce a probability of premature or low-birth weight delivery. Prenatal risk assessment also assesses the probability of adverse perinatal outcomes (Murata et al. 1992). Prenatal evaluation continues with urin e analysis and blood tests for rubella, hepatitis B, gonorrhea, chlamydia, genital he rpes simplex and HIV. Where available, screening for congenital fetal disorders, like Downs syndrome, neural tube defects and Rhesus isoimmunization are performed (Oldenet ti et al 1996). Screening for anemia is important in Mombassa because of the high prevalence of malaria and sickle cell anemia. The diagnosis of common pregnancy compli cations, such as intrauterine growth restriction, post-term pregnancies, pre gnancy induced hypertension and gestational diabetes, is necessary to prevent adverse out comes. Reassessment of the mothers wellbeing continues throughout pregnancy al ong with education on the physical and emotional changes associated with pregna ncy. Women who follow th rough with prenatal care also get information about childbirth, br eastfeeding, and infant care classes. Despite the measurable benefits of prenatal care, women in developing countries do not adequately use the services (Berer 1999). What is adequate utilization of prenatal care? How much prenatal care is enough? With all the research, this is still a controversial question. In Switzerland and Singa pore (Sen et al. 1991), just three prenatal care visits are considered adequate, while in the United States, 9-12 visits are

PAGE 26

12 recommended (Kessner 1973, Kotelchuk 1994, St andards for American College of Obstetricians and Gynecologists 1985). Fo r over three decades, the Kessner Index (Kessner 1973) has prescribed nine pren atal care visits for a normal pregnancy. Kotelchuk (1994) Alexander and Cornely (1987) ar gue that the number of visits is less important than the content and timing of vi sits. Adding to the c onfusion, Mahan (1996) asserts that indices for judging the adequacy of prenatal care are not useful at all. Quality of prenatal care, he says needs to be judged at the local level. Outcomes of life or death or handicap are the ultimate measures of quality care (1996:418). The World Health Organization advocates that maternity care should be a multidisciplinary, holistic, demedicalized, yet evidence-based approach that involves women, and their families in decisions a bout their care (Chalmers et al. 2001). Fortunately, empirical evidence is availabl e on this problem. Munjanja et al. (1996) compared women in Harare, Zimbabwe, who had 12-14 visits with women who had six visits. Among the 16,000 participants in th is randomized field study, there were no significant differences in pregnancy outcomes, at the aggregate level, for women in the two experimental conditions. Based on this fi nding, I consider six visits as adequate prenatal care. Utilization and access of prenatal care services In 1998, a joint UNAIDS/UNICEF/WHO worki ng group announced an initiative to reduce perinatal transmission of HIV. The inte rvention was formulated to increase infant survival, based on a package of six components: Early access to adequa te prenatal care, Voluntary and confidential counseling and HIV testing for women and their partners,

PAGE 27

13 A short course of perinatal antiretroviral treatment for HIV positive women before delivery and th e newborn at birth, Improved care during delivery, Counseling and support for safe infant feeding practices (Berer M 1999:872). Many studies show that cultural, structural, and infrastructural ba rriers to prenatal care all play a role in determining the ra te of adverse outcomes of pregnancy. (See Mabina et al. 1997, Lang and Elkin 1997, Goodburn et al. 1995, Campbell and Kelly 1995, Wall 1998, McCray 1982 and see Pare des et al. 2005, Romoren et al. 2005, Manadhar et al. 2004, Nigenda et al. 2003, for recent examples. See Medley et al. 2004 for a review.) The study I report here focuses on Muslim womens access to prenatal care and their actual health-s eeking behaviors in Mombasa. Pregnant women cannot get HIV testing and counseling unless they go to a pren atal care health cente r that provides these services. A positive HIV test is the entrance fo r perinatal intervention to decrease MTCT. The challenge that health care providers a nd researchers face has been to understand womens rationale for not using preventative services even when they are aware of the benefits. It is not necessarily the co st of services that prevents women from fully using prenatal services, but living a crisis existe nce and dealing with issues of financial difficulties (McKinlay and McKinlay 1972:377; and see Celik and Hotchkiss 2000, Jelley and Madeley 1983, McKinlay and McKinlay 1972, Sargent and Rawlings 1991, and Wilkinson et al. 2001). For example, user fees for preventative primary health care were removed in South Africa in 1994 but this did not improve prenatal care utilization

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14 (Wilkinson et al. 2001). By contrast, lo w-income HIVpositive African-American women on Medicaid in New York improved thei r use of prenatal care (with concomitant improvement in birth outcomes), once a program was implemented to enhance the womens understanding of health-seeki ng behaviors (Turner et al. 2000). Studies of African-American, Mexican-Amer ican and Puerto-Rican women in the United States indicate an association of low socioeconomic status (SES) and marginalization with low-birth weights, premature deliveries and adverse pregnancy outcomes (Echavarria and Parker 2001, Gar dner et al. 1996, Lia-Hoagberg et al. 1990, Petitti et al. 1990, Turner et al. 2000). In Brit ain, Petrou and colleagues (2001) infer that women of Pakistani and Indian origin made fewer prenatal care visits than attendance made by white British women, possibly due to cultural and religious beliefs. Magadi et al. (2000) in their study of frequency and timi ng of prenatal care in Kenya state that womens attendance was inconsistent, suggesti ng further research of traditional beliefs, religious and cultural practices. Other demographic factors included in mo st of the above studies included age, parity, obstetrical histories and desire for the pregnancy. Teenagers and uneducated women under-utilize prenatal care services (M cCaw-Binns et al. 1995 ). There is also documentation that prior adverse obstetric ex perience is a barrier to seeking early care (Ivanov and Flynn 1999). Lack of support from family and friends, pa rticularly to assist with childcare or transportation, is a structural barrier to the use of prenatal care (Winston and Oths 2000). In some societies, women have to ask for pe rmission from their part ner, their in-laws or their co-wife before leaving the household. Th e permission giver must therefore be an

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15 advocate of biomedical health care. In Momb asa, the saying that pregnancy is not an illness implies that women should not use the need for prenatal care as an excuse for not fulfilling their familial and social obligations during pregnancy. The saying is clearly a cultural artifact, but it belies a structural barrier, because so much of daily life (cooking, cleaning, and taking care of infants, taking ca re of sick and frail relatives and friends) depends on womens remaini ng active during pregnancy. In terms of infrastructure, the sheer pres ence of low-cost, easy-to-reach clinics can have an impact on the rate of use of prenatal care. Women often say that they are put off by the long lines at clinics, inc onsistent health care providers the lack of female staff, and a general lack of confidence with the hea lth care system (Barnes-Josiah et al. 1996, Handler et al. 1996, Ivanov and Flynn 1999, Maye r 1997, Petrou et al. 2001) Despite the importance of these factors, al l the evaluation studies just ci ted agree that strong rapport between the pregnant woman and her health care provider increases womens health attendance. HIV positive women and the utilization of health care Good communication between health care providers and pregnant women with HIV is all the more important because these women deal with the challenges of taking care of themselves, their families and their ch ildren in an environment of fear, guilt, stigma, uncertainty, and limited access to in formation and health care (Bunting and Seaton 1996:563). Lack of privacy is a major satisfaction issue in health care centers in Mombasa due to overcrowding. In order to create privacy, counseling rooms for HIV positive women have been made available in a few facilities through Horizons Project of the Population Council a USAID venture (USAID 2001). Unfortunately, unlike other pregnant women, HIV positive pregnant wome n have an added concern while attending

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16 prenatal care clinics the fear of disclosure of their HI V status to a spouse or boyfriend, family member, neighbor or co-worker (Sobo 1995). Walter et al. (2001) found that, though ne w mothers were not knowledgeable about perinatal HIV transmission and did not trust he alth care institutions ; this did not deter some of them from seeking health care. Oldenetti et al. (1996) found that HIV positive women believed that every woman should have the option of being te sted but that HIV testing should not be done unless counseling and treatment are available. Sobo (1995) found that women trust clinicians who show empathy and a non-judgmental attitude and who do not pressure women to disclose thei r HIV status. Given this, Sobo recommends straightforward communicati on to reduce misunderstanding. Ingram and Hutchinson (1998) reported that HIV positive women felt oppressed and discriminated against by society and by the health care profession. These women, they say, use various coping mechanisms in or der to lead normal lives alternately concealing their HIV status from strangers or looking for sympathizers in society. In a follow-up study, Ingram and Hutchinson (1999) sa y that some women develop an attitude of defensive mothering to protect their children against stigma. These mothers did not hide their HIV status from friends and fam ily and took extra precautions in their health behavior and practices. The n ear-universal directive to re produce provides a woman with a different status during pregna ncy. Babies represent source s of love, acceptance, and a legacy for the future, say Ingram and Hutc hinson (ibid: 243) even for a woman with no sense of future for herself. Other studie s show that guilt and the fear of dying and leaving children behind can become an em otion that dominates womens reproductive decisions (Sowell and Messner 1997, Williams 1990).

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17 Much of the researches on cultural and so cial barriers to pr enatal care for HIVpositive women have been done in the United States. The MTCT problem is greatest, however, in developing countries The research I report here contributes to the research called for by Reeves et al. (1999), among others, on HIV positive womens knowledge about MTCT, and the barriers that prevent them from using available prenatal and perinatal care.

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18 CHAPTER 2 MOMBASA THE RESEARCH AREA Geography Mombasa is located off the coast of East Africa. As Kenyas second city, it is the main seaport and the capital of the coast prov ince. Kenya has seven provinces; the coastal province is one of them. The island of Momb asa adjoins the coastal hinterland; it is symmetrically oval, three miles long and five-a nd-one-half square miles in area, lying on a northwest-southeast axis (Stren 1978). The connection of the island to the mainland is the Nyali bridge in the north, the Makupa cause way to the west, and a daily ferry service in the south. The whole coastal region has a tropical climate with northeast and southeast having monsoon winds. The harbor has deep wa ters providing excellent channels for anchorage and access for large cargo ships, t hus providing access for visitors from around the world (Ntarangwi 2003). Figure 2-1. Map of Kenya situating Mombasa

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19 History: The Visitors and Administrators Strobel (1979:22) explains th at in the 750 years of its recorded history prior to colonial rule, Mombasa absorbed one wave of migrants after anot her, each contributing to its culture. Mombasa became culturally diverse due to traders from the Indian subcontinent, Ceylon, China, and north and central Africa, and administrators from Arabia, Portugal, and lastly Britain. These la tter groups have left a lasting impression on the societys politics, economy and culture. Mombasa was an urban coastal settlement according to the geographers, al-Idrisi and Ibn Batuta who visited the area in the twelfth and fourteenth century. Arabs and Persians initially came to Mombasa to trade. The Arabs ruled the East African coast due to wars among the existent feudal rulers at the coast. Conversion of the local inhabitants to Islam was not an initial goal. Accordi ng to Pouwels (1973) Islamization in Mombasa took two phases, with a stronger conversion em phasis after 1300. This has been reviewed extensively by Berg (1968), Davidson ( 1991), DeBlij (1968), Mazrui (1995), Prins (1961) and Salim (1973). The coastal people na med Mombasa, Mvita or Isle of war due to the many conflicts, instigated by the Arabs and the Portuguese, and later the Arabs and the British, and the inhab itants against the intruders. There was a long period of unchallenged Arab domination which ended when the Portuguese arrived in Mombasa in 1498. The establishment of Portuguese power along the coast was greatly facilitated by the tension between the various coastal city-states and their Arab rulers. The period of Portuguese domination, lasted from 1500-1700, a time of constant clashes with the inhabitants, with assistance by the Arabs. The Portuguese had a reputation of greed, corruption and dishonesty (Kirkman 1964, Salim 1973). Dissatisfaction led to a number of rebell ions and revolts with the burning down of

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20 Mombasa on two different occasions. Othe r than economic interests, the Portuguese brought Augustinian missionaries to convert the inhabitants but they met with little success (Freeman-Greenville 1980: xxvii). Th e Portuguese built forts and garrisons along the coast in order to contro l this area of the Indian O cean. The Portuguese culture and language made a minor impact on the local Swahili culture (Abdulaziz 1995:144). However, they introduced crops such as, maize cassava, cashew trees, avocado, guava and tobacco (Salim 1973:4). The Portuguese withdrew to Mozambique after numerous rebellions and riots (Kirkman 1964). Mazrui (1995:4) explains that there was a power vacuum in East Africa during the 18th century and the early 19th century after the removal of the Portuguese. From 1698, the Yarubi dynasty in Oman placed the M azrui family as governors of Mombasa, and they ruled for 139 years. By 1812, the o ccupation of the Sultan of Oman was more evident with the presence of a powerful na val and military force in the Indian Ocean, incorporating the coast of East Africa as part of th e Omani kingdom. Abdulaziz (1995:145) asserts that this was the beginni ng of a new era of political, cultural and economic change on the East African coast. Other immigrants were brought from other countries, such as Hadhramut, Baluchi, and Indi a to act as laborers, officials and soldiers. The local culture and life-style became integr ated with that of these immigrants in language, dress and clothing, architecture a nd cuisine. The diversity was solidified through inter-marriage with the local inhabitant s. This was to become the Swahili culture and the people who adopted the language, a nd customs became the Waswahili. Kiswahili, the language has a Bantu structure; however Ar abic is evident in 40% of its vocabulary,

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21 and there are also a few Portuguese and Indi an words. The word Swahili in Arabic means coast and Waswahili means people of the coast. The Arab domination of the East African coast coincided with the ivory and slave trades Mombasa was a major slave receivi ng port, with some slaves remaining as domestic and agricultu ral laborers (Strobel 1979:30). The effort to end the slave trade on the Indian Ocean was one of the reasons th at the British entered Mombasa. Although the British abolitionists had humanitarian reasons to stop slavery, they also had political and economic motives (Mazrui and Shariff 1994: 31). British colonial rule began in 1895, ending almost two hundred years of Arab domination. The Britis h took administrative responsibility from the Imperi al British East African Comp any, and made East Africa its protectorate with Mombasa as its capital. This changed in 1902 when the capital was shifted to Nairobi. Roads, railways, and ot her governing infrastr ucture were built to increase security and to improve the polit ical and economic advantage of the British administrators. These improvements not onl y altered Mombasas economy, but, as the Mombasas importance as a port grew, it also brought an influx of immigrants from upcountry (Ntarangwi 2003: 34). These new im migrants, whose ethnicities are Kikuyu, Luo, Luhya and others, were different from the coastal people in culture, religion and language. These immigrants were perceived by the established society in Mombasa to be aggressive, and uncultured and there was initial resistance in accepting them into Mombasas society (Foeken et al. 2000; Strobel 1979). Some of the so-called new immigrants have intermarried and assim ilated into the Swahili culture, including converting to Islam, with their offspring becoming Swahili.

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22 The Coastal People Waswahili Many scholars have tried to determine th e origin of the Swahili culture and its people (Berg (1968), Chami (2002), Mazrui a nd Shariff (1994), Nurse and Spear (1985), Salim (1973), Strobel (1979), Swartz (1991) and Willis (1993)). The prevailing theory focuses on the fact that the initial groups of people in Mombasa called themselves the twelve nations ( ithnashara taifa ). These twelve nations ar e divided into two groups, one group of three ( miji tatu ), comprising the WaKilindini, WaTangana and WaChangamwe, and a group of nine ( miji tisa ), comprising the WaMvita, WaJomvu, WaMtwapa, WaKilifi, WaPate, WaPaza, Wa Shaka, WaGunya and WaKatwa. Each group, or nation ( mataifa ), had its own political repres entative who governed through Arab and Portuguese rule. This system disintegrated, however, under the British. Most of the people belongi ng to these groups referred to themselves by their ethnicities and do not call them selves Waswahili (this occurre d as well when I questioned ethnicity in this research). According to Salim (1973:1-6) these groups are what constitutes the Waswahili. He further defines the Waswahili as people of the coast with a similar languagethat is, Kiswahiliand havi ng a culture influenced greatly by the Muslim faith. He finally claims that the Swahili do not form one tribe claiming one ancestor. The Waswahili are the result of mi xing and intermarrying between Africans and immigrants. Willis (1993:12) argues that there is no single definition of the Swahili: different people, in different situations, may appropr iate this ethnonym or apply it to others according to their perception of their advantage. This argument stems from assessment of the Waswahili in three areas. First, during British colonialism, for the enforcement of taxation and other laws, the differentiation of natives and non-natives served as a

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23 basis for people to define themselves to their economic or political advantage (Stren 1978:32). Secondly, after abolition of sl avery, a freed slave became Swahili, by converting to Islam, thereby ac quiring status as a non-slave ( muungwana ). Thirdly, after Kenyas independence, to be accepted into the new political arena as a mwananchi (a term reserved for an indigenous African), people who had claimed Arab or Persian ancestry now had to disassociate themselves from being anything other than African. Another group of people in Mombasa ar e the Mijikenda, comprising nine Bantu ethnicities; the major ones are the Digo (alm ost all Muslims) and the Giriama. The Mijikenda have also intermarried with the Arabs and Waswahili, some calling themselves Waswahili, although the majorities have kept their ethnic identities. Some of the Mijikenda were also added to this study because of the sharing of cu lture, particularly in healing. How has the history influenced society?: Among these ethnic groups in Mombasa, some cultural practices are shared while others are not. For example, healing for high blood pressure ( mwajuu ) in pregnancy is done by the Mijikenda, but Arab women use the treatment. During my fieldwork, I observed and listene d to women as they complained about demands on their time that kept them from ta king care of things like preventative health care. Some of these demands include visiting friends, neighbors and relatives; attending ritual events such as weddings, circumcisions births, and funerals; and religious studies. While these activities take time, they also provide a network of emotional and practical support, access to jobs, goods and informa tion and insurance against economic and personal calamities (Holmes-Eber 2003:9-10).

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24 What Occupies Womens Time in Mombasa? Society and Culture Visiting friends and relatives: Visits to friends, neighbor s or family are made by women mostly in the late afternoons, but can occur at any time during the day. These visits are done after women have finished their other duties of cooking, cleaning and childcare, or for those who work in the form al economy, after work. Fitting in a hospital appointment for preventative care becomes di fficult for some women who have to plan for visits. The visits are informal without previous announcement and can be a quick just checking to see how you are ( nimekuja kukujulia hali ) or a full day ( kushinda ) depending on the purpose of the visit. Visits ar e considered social, cu ltural and a religious obligation, particularly when visiting the si ck. Depending on the duration of the visit, drinks such as tea, coffee or soda may be served. On these visits, exchange of information, chit chat or gossip takes place from the latest fashions, births, weddings or funerals to be attended or checking on othe r family members. Holmes-Eber (2003) in her research of women in Tunisia analyzes visits as important survival strategies for women. In addition, she asserts that match-making and arranged marriages take place as young people visit and meet at these social gather ings. There is no specific word in Mombasa that describes the word visit, except word s that explain what th e visit is about, for example I am going to visit the sick ( nenda kumtizama mgonjwa ) or I am going to pay my respect to the deceased family ( nenda kuwapa pole waliofiliwa ). Visits are reciprocated particularly for the sick. A woman who visits others also receives visitors ( atakae watu na yeye hutakikana ) when she or a family member gets sick. A visitor will cook and clean and help with the general upkeep of the house. Furthermore, if the sick is admitted, the visits continue at the hospital. Hospital administrators and clinicia ns (especially those from upcountry) voiced concern and

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25 frustration due to these visits, because of the amount of people that come to see or stay with the patient. Hospital ru les that are strict and impose special times and number of people by a patients bedside are criticized, at times creating conf lict between hospital personnel, relatives or friends. The hospital administrators, unders tanding the culture, allow one relative to stay with a patient at a ll times, and leave this pe rson to be the liaison to the other relatives or friends not allowed in. The advantage to cl inicians is having a family member to assist in caring for the sick, especially when there is shortage of staff. The disadvantage however, is the lack of pr ivacy for other patients and taking time to explain procedures to the patie nt and relative. Information about the patient s condition and interaction with hospital pe rsonnel is relayed to other vi sitors. Even an infectious disease does not deter a family member from staying with the sick. Desertion of a sick family member is considered inhumane, lead ing to other community members criticizing, scolding or ostracizing with comments such as, how could you ne glect your sick? ( vipi mumemtupa mgonjwa wenu ?). These comments are also made if a relative does not take of a woman who has given birth. Having a sick family member obligates a woman to stop visiting others, or being involve d in social activities. She is expected to take time off work and stay home to take care of the sick. Other relatives take turns and participate in the duties of caring. The help from other fam ily members include when and how to seek for health care providers. Grandparents or older family members not living in the same household, as well have to be visited and greeted whether daily or at least weekly, even when they live with other family members who take care of them. Vi sits increase when the elderly get sick or a sick persons condition deterior ates or at the time of death.

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26 Funerals: Before death or when a person dies the relatives and close friends gather to pray and perform th e last rites. Attending a funeral is assurance that an individual will get a decent burial at death. A womans last rites are performed by women, and mens by men. The corpse is left in the house where she or he died, and if the individual died at the hospital, the corpse is brought to his/her home for the last rites. Following Islamic rules of the last rites, the body does not undergo post-mortem unless foul-play is suspected and aut horized by the law. The burial is conducted on the same day or within twenty-four hours af ter death for example, a person dying in the night is buried before sunset on the following day. A corpse that cannot be buried and has to be kept overnight is left in her or his home. Relati ves and friends gather in the deceased home and Quranic text or special recitations for th e soul of the departed are read. At times a religious teacher ( mwalimu ) and his students may be invite d to conduct these recitations during the day before or sometimes after th e burial. The one who washes the corpse ( muosha maiti ) can be a family member, neighbor or friend especially for women; however for men a designated community member has this responsibility. A large basin (in modern houses) is kept under a special bed without a mattress ( kitanda cha mwakisu ) used just for washing the corpse. In homes th at still have beaten earth or mud flooring, a hole is dug underneath the bed where the water drains. Pregnant women are excused from participating from perf orming funeral rites. During this research, there was controversy about the performance of the last rites in relation to people who die due to infecti ous diseases, such as AIDS. The community was divided, with one group agreeing to adopt the recommenda tions of HIV/AIDS activists and health care providers who wanted to implement the use of gloves and special

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27 training to be given to the washers in how to handle infected body fluids. Those who opposed such interventions argued that such practices would expose the family to the stigma that their family member died of AIDS, and also dishonor the dead ( kutuaibishia maiti ). It was decided that al l bodies should be handled the same way whether the individual died of an infectious disease or not. Wearing of gloves and careful handling of body fluids is now widely adopted, but not by all. Close relatives and friends spend three days after the burial at the deceased home. Money for food is collected from all the atte ndants and the mourners are fed. On the third or/and seventh day a gatheri ng that includes neighbors a nd some community members takes place to pray for the soul of the deceased ( khitma ) and a big lunch is done to feed them. This practice is now discouraged as non-orthodox Islam by the religious leaders, who argue of its significance, especially sin ce at times it places a financial burden on the mourners. Despite these protests, some people still continue with the practice. Weddings: Traditionally marriages were arrang ed between families, and some still do since a marriage involves the couple, both sides of the family and their relatives. Endogamous marriages are encouraged, followi ng the Arab intermarriage system, with parallel cousins being preferred. These are done to reinforce kin ties keep wealth in the family and increase parental control a nd protection of daughters (Holmes-Eber 2003:50). Womens education and occupation has increased exogamous unions and getting more and more societal approval. Wedding preparations can start months befo re the actual exchange of nuptials. The arrangements are done by the relatives with each member volunteering to organize one of the many festivities that fit into three to seven day. The men may have only one or two

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28 days of organizing, which incl ude the legal and religious as pect of the wedding. The size of the wedding depends on the wealth of the extended kin. The women involved undergo beautifying rituals such as re moval of all body hair (excep t the head) th rough waxing or threading, plus decorative staining of the hands and feet with henna. These get together parties might be held at either the br ide or grooms parents home or at a family members house. Most of the women feel obligated to part icipate, as explaine d by one, if you do not get involved, then nobody will come when it is your time ( nisipokwenda, halafu hakuna atakaekuja nikiwa na langu ). What used to be a neighborhood and community affair for most areas, wedding practices have now ch anged, with families providing special invitation cards to minimize the expense of weddings. Despite this change, many families undergo financial hardship due to these elabor ate arrangements. Sophisticated clothes and expensive jewelry mostly gold are at times bought or ordered from Europe or the Middle East. The more grand a function, the more stat us a family receives from the community. I met women I had interviewed who had compla ined about not having money to pay for health care, however they were adorned with very expensive jewels. When I questioned the attire, one protested that I do not want to embarrass myself ( sitaki kujiaibisha ). A woman, who openly displays her inability to dress well or adorn herself with the latest fashion and jewels, makes a public statement of being poor ( umaskini ), thus shaming her husband and family. Salim (1973), Strobel (1979 ) and Swartz (1991) de scribe further the details and responsibilities of the sexes, and the daily festivities for each day in a typical wedding. Ntaragwi (2003) moreover illustrates the types of music for each occasion.

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29 Some women prioritize their time differen tly, and are very selective of which activities or visits to atte nd. These are mostly professional women who are busy and find it hard to keep up with the day to day fam ily and social activities. Another group of women are those who attend religious classes ( darsas ). These women excuse themselves from non-religious related activ ities in the community. These darsas involve a lot of time for the organizers and the participants. They take place mostly in the evenings, about three times a week. I attended one of these meetings, just as I had attended weddings, funerals, visited a relatives son after a circumcision and numer ous visits to sick friends and relatives. At the darsa, I was invited to talk about my research, and discuss my evaluation of womens hea lth issues in Mombasa.

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30 CHAPTER 3 MEDICAL PLURALISM IN MOMBASA Introduction Fabrega (1997: 12) has defined medical pl uralism as a theoretical framework to explain the differences between the dichotom ies of disease/sickness and illness/healing. Within medical anthropology, disease/sickness explains th e biological or psychological processes, diagnosed and treated within a We stern biomedical framework. Illness/healing on the other hand explain an individuals and his societal psychosocial interpretation and management of sickness, (Fabrega 1997, Kleinman 1978, Waldram 2000, Young 1981). Waldram (2000: 605) further argue s that, every medical system is a cultural system and is engaged in both healing and curing. The practice of medical pluralism is universal with the incorporation of alternative or complementar y therapy, which may include homeopathy, herbals, natural healing and holis tic therapy. In non-We stern societies, the use of traditional medicine and some of the above practices are incorporated with methods to include indigenous and religious healing rituals. The word for health in Kiswahili is afya which is a holistic concept that goes beyond that set by the WHO to include wholen ess, safety and strength. The healing processes for ill health include attention to social relationships, emotions and religious spirituality and conformity with tradition (Boerma and Bennett 2000: 261). Ndege (2001: 90) adds that being in good health not only includes the biological functions of the body, but also embraces the political and econom ic forces that impact the body (Janzen 1978).

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31 Each healing practice, according to the be liefs of pluralistic health systems, is incomplete. For example, among the women I studied, biomedicine has antibiotics that can take care of respiratory in fection, but the antibiotics can not take care of the wind that might have caused the bodys physical imbalanc e. If any given tradition is incomplete, then pluralism makes perfect sense. In Momb asa, cultural healing pr actices include home remedies, traditional/folk healers, herbal practitioners, Muslim and Christian spiritual healers, charlatans, drug vendors, biomedical hospitals, and public and private health centers. Kleinman (1978: 86) asserts that illness is experienced and reacted to in three sectors: the folk/traditional, the professiona l and the popular. He fu rther explains that groups have cultural categories that they or ganize various types of illness and methods of treatment (Ware et al. 1989: 24) I have incorporated Islamic medicine and healing practices within all these sectors since it is part of Mombasas pluralistic health care system Biomedical Health Care Biomedical or clinical medicine in Mo mbasa is organized und er the governments Ministry of Health (MoH), with headquarter s in Nairobi (the capital of Kenya). The government runs and owns about 51 percent of the health facilitie s countrywide (Owino 1998). Overseers assigned from the government headquarters implement health policies, maintain quality standards of care and contro l all resource allocations to provincial and district health activities. Nongovernmental, private-for-profit a nd mission organizations run the rest of the facilities. For further detail s of the history of health care and the health care infrastructure in Kenya see Beck (1981), Mburu (1981), Ndege (2001) and Nyamongo (1998). In addition, Obonyo and Owino (1997), Owino ( 1998), and Owino et

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32 al. (2000) have written on the financial a nd managerial challenges Kenya faced from independence (and continues to face) and gui delines needed to improve deliverance of efficient health care services. Health car e for all used to be free in Kenya until 1989 when cost-sharing programs were implemen ted after the introduc tion of structural adjustment programs to assist the state w ith economic health management (Wanyande 1993). The main maternity hospita l in Mombasa, named Lady Grigg, is located at the Coast General (Provincial) Hospital (CGH). The hospitals administ rative responsibilities are handled by the Provincial Medical Officer and his or her executive team. There are two ways that women can get prenatal care: through CGH and from the health department run by the municipal council. Th e CGH provides prenatal care services under the preventative health care system. These serv ices are also offered in seven department health centers in Mombasa. These centers, however, are managed and financed by the Ministry of Local Government, represen ted by the local Muni cipal Council. The complexity of this system has been summa rized well by Schaefer (1981:130) who states, often the government of the central city has no authority over other towns in the conurbation, and rival local governments ma y pursue uncoordinated and contradictory policies. This lack of coor dination was especially eviden t in Mombasa for pregnant women who presented with complications and needed advanced health care. Women with complicated pregnancies are referred to CGH wh ere there are advanced medical facilities. Communication between clinicia ns who examine women at the health departments and obstetricians at CGH is almost non-existent CGH does not deal only with women with complications from Mombasa Island, but also from the adjoining districts that comprise

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33 the coast province. This province has a population of over two million. Despite the inefficiencies at the municipal level, prenat al care services provided for women at the CGH were well-organized, with formal edu cational classes given or televised while women waited for services. The instruction gi ven to women covered nutrition (for them and for their infant), childbirth, infant care, breastfeeding, and prevention of malaria, anemia and HIV. I did not observe these cl asses being offered at the non-government institutions. The major private (for profit) hospitals in Mombasa are the Aga Khan, Pandya and Mombasa. These hospitals have physicians who provide care for their admitted patients and prenatal care in their offices or clinics. These hospitals are efficient and expensive, charging approximately Kenya shillings (Ksh.) 20,000 to 40,000 (about $ 250-400) for childbirth without complications, compared to the government hospital or birthing centers that charge Ksh. 30004000 (about $30-50). Women who use the private facilities are mostly insured, either by the National Ho spital Insurance Fund (NHIF) or by private insurance. In Kenya the NHIF is mandatory for all salaried employees earning taxable income, though it reimburses only hospital care (Owino 1998). The nongovernmental facilities include the African Medical and Research Foundation (AMREF), UNICEF and various providers from religious charity organizations. Furthermore, there are numer ous for profit out-patient clinics manned by one or two health professionals that charge reduced fees fo r health care services. In the late 1980s, the Ministry of Health allowed health care workers such as nurses and clinical officers (physicians assistants) to engage in private pr actice (Obonyo and Owino 1997). This government ordinance led to the opening of numerous out-patient health

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34 centers, pharmacies and small hospitals that serve about five to twenty in-patients, providing curative and preven tative health services. Christianand Muslim-run not-for-profit ch aritable hospitals that charge minimal fees are among these varied heal th care facilities. My resear ch concentrated on three of the Muslim-run establishmentsthe MEWA, Sayyida Fatima and Al-Farouk hospitals. These hospitals were in neighborhoods where al most all the inhabita nts were Muslims. This proximity increased womens attendance wh en they needed maternity health care. In addition, the cost for prenatal care and childbirth was almost a third less than that charged at the other private institutions. These thre e hospitals had a total capacity of 80-100 inpatients. Each had a small emergency room th at managed minor cases of immediate care, facilities for small surgical procedures, a pharmacy, a laboratory and an out-patient facility. Moreover, they had qualified physicians (some work ed privately, some were employed by the hospital), nurses, midwives and other various hos pital personnel. The majority of the staff and their clients are Muslims, though there were a few non-Muslims. The sense of familiarity that comes from r eceiving care from staff of similar religious beliefs and culture increased encourages some women to use these facilities. Nevertheless, I heard complaints from se veral women of nurses being unhelpful and arrogant. Criticism also stems from inflexib ility of hospital staff in rejecting certain cultural practices, like the release of a corpse immediately after death. Islamic practice is to bury within twenty-four hour s. This becomes a problem since hospital rules (imposed by the government) require that a ll the right documents be file s or that a post-mortem be done before a corpse is released. This tug of war between religion, culture and biomedicine affects the relationship of the local community and clinicians. Quite a few

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35 community members asked: What is the us e of having a Muslim-r un hospital if they cannot understand our needs? Th e wide knowledge gap between health care providers and their patients or kin at times created te nsion when they dealt with each other. Some women offered these conflicts, created by the hospital administrative system, as their reason for choosing home-based birthing centers. Birthing centers are operated by nurses, mi dwives, clinical officers (physicians assistants) or, occasionally, a physician. There one or two clinicians at these centers employ a non-licensed assistant to help with management tasks. The volume of patients is lowfrom five to twenty parturitions a month. Prenatal care is not efficient or consistent; some of these centers have a small laborator y that can perform minor services, such as hemoglobin levels and urine tests. Women are sent to private labor atories and pharmacies for services if needed. Women who avoid hospitals because of rigidity assert that this atmosphere is preferable. On the other ha nd, women who need advanced medical care do not receive it at these centers, with detrimental consequences for their health. Basic biomedical equipment is used during childbirt h. Instruments are sterilized; birthing beds are used with stirrups when needed. Minor su rgical procedures such as episiotomies and circumcisions (of male infants) are perf ormed. One of the major complications of childbirth is postpartum hemorrhage. Oxytoc in, or ergometrine, a medication to stop bleeding, and intravenous flui ds are given to women who are beginning to hemorrhage before they are rushed to a hospita l that can provide advanced care. The atmosphere in these centers is relaxe d, jovial and comfortable. Women are not rushed and services such as body massages ar e available for a fee. Biomedicine, home remedies and traditional healing practices are combined. For instance, a woman

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36 diagnosed with anemia is given iron pills, advi sed to drink a mixture of raisins and spices ( sikijabili ), and receives advice in the form of a Quranic verse that she can recite to get rid of hassad (evil eye). The health care network starts from these neighborhoods maternity facilities moving up to the Lady Griggs / Provincial hospital where women are referred for complications. The private hosp itals and the CGH have more sophisticated diagnostic, therapeutic and rehabilitative services. With the HIV/AIDS epidemic in Mombasa, most of these other facilities do not have the tr aining to assist HIV-pos itive women or their infants in therapeutic care duri ng pregnancy or at childbirth. Traditional/ Folk Medicine Healers have for long been treated like trees on savanna farms not formally cultivated, yet valued and used, particul arly by women and children (Chavunduka and Last 1986:259). The traditional healer ( mtabibu ) has been defined as the witch-doctor ( mganga ), diviner, medicine man, herbalist or so rcerer. In an urban area like Mombasa, biomedicine is politically the only legitimate and acceptable form of health care service, though the herbalists and diviners continue to practice publicly (Mburu 1992). Ataudo (1985: 1345) describes African traditional medici ne as the totality of all knowledge and practices, whether explicable or not, used in diagnosing, preventati ve or eliminating a physical, mental or social equilibrium and wh ich rely exclusively on past experience and observations handed down from generation to generation, verbally or in writing. Traditional healers in Mombasa are both male and female and they practice for both sexes depending on ailment. However, pregnancy related illnesses are treated by traditional birth attendants (TBAs) who have various degrees of knowledge in herbal remedies. In addition, practices such as massage therapy are done only by women

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37 healers. Healers as well use an extensive sy stem of classifying illnesses according to signs and symptoms and suspected cause. Their system is dynamic and increasingly incorporates biomedical knowledge (Boe rma and Bennett (2000: 262-263). This was evident during observations and interviews with TBAs. Almost all TBAs stated that they used gloves and dettol (antisep tic solution) while assisting in childbirth. I observed them giving pain relievers such as (Panadol/Tyl enol) and Chloroquin to treat malaria. In Mombasa, TBAs are sent for educational trai ning to the provincial hospital to learn about complications in childbirth and preven tion of HIV from c ontact with body fluids. This has been promoted and encouraged by UNICEF. The TBAs who receive such training are registered with the neighborhood chief. Mombasa Island has seven chiefs who function under the administrative structur e of the Municipal C ouncil. These chiefs have the responsibility to regist er births and deaths in thei r locations. They also keep a log of all practicing TBAs. Not all women who give birth in the neighborhoods are assisted by registered TBAs. Almost all of the TBAs stated that they did not have formal education or training, but had learned from observation. They stated that they received their training to assist in bi rths from their mothers, gra ndmothers and/or other female relatives. A few TBAs stated that they had wo rked in hospitals as nursing assistants and had learned from observation. There were two TBAs who declared that it was a spiritual obligation, since they were called to healing. TBAs charge about Ksh. 2000 (about $25). They do not demand payment before they render their services, and some barter for other goods or services when financial paymen t is impossible. They are also flexible. They go to womens homes befo re a birth, and will stay to assist with the care of the mother and baby if they are not called away for another birth.

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38 During the interviews for this study I talk ed with 12 women w ho had assisted in births, but I spent a lot of tim e with and directly observed two TBAs (see Chapter 4) who were conducting the most deliveries in Mombas a. I also interviewed five male healers. These interviews were not included in the qua ntitative analysis, but they added depth in understanding healing in Mombasa. The purpose of healing, I was informed was to regain balance or return the body to the state of w ellness by finding out what has afflicted the body or interrupted or disturbed its function. These healers at times had their own herbs and remedies which they prescribed and offere d to their patients. Alternatively, they sent their patients to herbalists with prescriptions. Herbalists are important healers in Momba ssa, they are mostly male, and their fees vary depending on the ailment. The herbal ists have an empirical knowledge of the midicinal properties of selected leaves, bark s, saps, roots and other natural products. The use of herbal medicines begins at home in Mombassa. One tree, the muarubaini, was said to be useful in the treatment of treat fo rty different ailments. Drinking a boiled potion from the leaves of the muarubaini treated fever associated with malaria, flu or pneumonia. The herbalists in th eir shops or at the market pr epared and sold what could not be provided in the home. On the street s are also charlatans who claim knowledge and competence in healing but prey on individuals who are desperate for treatment. There are two types of herbalists, one who has a dia gnostic and treatment center, while the other sells his ware at shops or the market place (Beck 1981, Good 1986, Mburu 1992). The most frequented herbalists in Mombasa ar e in two shops, one located in Old Town, owned by an Indian healer. He stated th e shop has been family owned since 1873, and supplies the town with therapeutic treatments from India, China and the Middle East. The

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39 second shop in Mwembe Tayari provides mo re local herbal remedies, though here, too, non-local medicines are ordered from Tanzania and the Middle-East. The owners of both stores explained that they did not diagnose or prescribe treatments. There are other herbalists across Mombasa. Some sell their tr eatments at the local market. Others sell along the road, where people stop to make purchases. Women herbalists who treat pregnancy related conditions practice mostly from their homes, though a few have stalls at the market (see Chapter 4). Diviners are perceived to have a special gif t or supernatural powers. They vary in skill levels, specializat ion, knowledge and beliefs, the types and organization of therapy they provide, and personal mannerisms. Di viners in Mombassa claim, and some are believed to have the ability to diagnose and prescribe treatments, though do not offer treatments. The diviner gives the ultimate etiological conditions of a psychic, somatic or psychosomatic disorder, interpersonal al liances and conflicts (Mburu 1981:172). The importance of balance in interpersonal relati onships is part of being a moral person. Fairness in the treatment of others protects a person from misfortune and illness. Wishing ill or hostility on another person also brings harm to oneself ( mchimba kisima huingia mwenyewe ). In addition, unresolved social relationships are viewed as causes of poor health. For example, a pregnant womans weight loss might be attributed to poor nutrition, her relationship with her mother-i n-law (who might not ha ve accepted her) will also be seen as associat ed with her poor health. A common Swahili is that daktari si Mungu (the Western doctor is not God) leads individuals to seek other local traditiona l/religious therapists. The incorporation of Muslim diviners/healers differentiates the us e of diviners from ot her non-Muslim groups.

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40 The Muslim cleric, who is almost always a ma n, has a role as a diviner by using texts from the Quran, astrology, numerals or rosa ry. He also divines through dreams, spirit possession and necromancy (1980: 84). Islamic Healers Islam affirms the power and will of A llah in all things, including suffering (Whyte 1997:47). Faith, illness and healing go hand in hand and it is common to hear a sick person and his or her ther apy managers to state that th e outcome of the illness is Allahs will. Cure does not take place if not willed by Allah, and fatalism is the doctrine sometimes adopted by believers (Feierman and Janzen 1992). Islamic medicine in Mombasa dates from the 8th or the 10th century (Trimingham 1980), and is still practiced. Islamic healers incorporate Prophetic (Arabic) and Galenic humoral medicine to view health and asse ss the bodys response to illness. Humoral medicine emphasizes on the hot/cold di chotomy, specifically in foods and the environments. Greenwood (1981) and Morsy ( 1993) provide a detailed narrative on humoral medicine in Morocco and Egypt whic h jibes with similar beliefs in Mombasa (see Chapter 6). From a similar perspec tive, but adding womens knowledge about pregnancy and the practices surrounding chil dbirth, Obermeyer (2000) has investigated medical pluralism and humoral medicine in Morocco, while Manders en (1981) describes humoral practices and childbirth in Malay. The imbalance demonstrated by disease is said in this system to be due to features of physical and spiritual bodies Physical imbalance can be caused by exposure to the environment. Imbalance related to the e nvironment is caused by the air or wind ( upepo ), cold or hot temperatures. A woma n complaining of having a fever ( homa ) could be reacting to her bodys discomfort to environmental heat or cold.

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41 Food intake, lack of sleep or rest, and ones emotional state (Abdalla 1992: 182) are related to certain illnesses. Emotional state is similarly linked to balance or imbalance of hot and cold. A hot tempered person suffers from headaches, while a cold natured individual gets depressed ( baridi ya bisi ). Healing consists of rest, diets, fasting, an array of medicines, and the extraction of impurity by bleeding, scarification or branding, vomiting or use of enemas (Slikkerveer1990). There is also a belief that spiritua l beings cause illness. Morsy (1993: 111) describes them as subterranean beings and assigns their effects into two categories, direct and indirect. Direct spirits afflict individuals th rough possession, while indirect beings are controlled or manipulated by others through sorcery. Waite (1992: 214) explains that spirits are believed to bring certain kinds of illnesses and other afflictions to individuals, to families and to the whole communities. She specifically identifies ancestral spirits, which represent the founders of an individual family. In Mombasa these are termed majinni ya ukoo and those of the community/territory ( majinni wa mji ). Spirits in Kiswahili are called jinni (plural majinni ), pepo or ruhani. These are mischievous and although they may cause discom fort, they do not cause serious illness or death. For instance, a woman who has a ruhani can be pregnant for more than a year, (see Chapter 6) and will not deliver until the ruhani is appeased. Spirit possession can take many forms, from mild affliction (where a person portrays physical discomfort) to altered social behavior. Se rious symptoms of suffering include body weakness, loss of appetite, loss of weight, headaches, and sometimes shaking of the body. Sorcery accusations reflect strained social relati ons and could be due to revenge. Sorcery can be used to create infertility, impotence or deaths of infants.

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42 The evil eye ( jicho) or hassad, refers to harm inflicted on an individual due to feelings of envy or jealousy. In Islam, hassad is legitimized by reference to Quranic descriptions of the ma levolent power of the hassid. or possessor of the evil eye (Morsy 1993:110). Hassad is associated with creating mi sfortune, illness and even death. A woman who says that someone elses baby looks healthy might be the target of blame if that child suddenly becomes ill. Her eye, whether consciously or not, would be the cause of ill-health. Women who have miscarriages or infant deaths might be asked if they are objects of hassad (je umehusudiwa ). Moreover, when a multitude of misfortunes occur in a household, the inhabitant s question if the home has hassad, which. if true, would require a healer to diagnose and remove the cause of the hassad. Hassad is different from sorcery which is associated with shirk or the acceptance of a power greater than Godthe gravest, mo st unpardonable sin in Islam (Feierman and Janzen1992). Superstition and prac tices associated with it are slowly diminishing due to Western education and culture on the one hand, and Islamic orthodoxy on the other. Muslim women who still go to diviners or healers that believe in sorcery do so secretly. This practice is associated with he retics and therefor e sinful (ibid). S harifs are people who claim genealogical descent from the prophet Mohammed. They assert, or are imputed by their followers, to possess baraka or special blessings from God, which can be used in he aling (Beckerleg 1994). Besides the sharifs, there are also scholars of the Quran ( maalims) with knowledge of Islamic law and Arabic medical texts. This body of knowledge is taught lo cally or in the Middle East. The emphasis on treatment for hassad or spirit possession is based on theories of balanced hygiene and diet, and also, at times, exorci sm. Portions of the Quran are prescribed, and written to be

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43 worn as an amulet. It may also be written with food coloring on a plate, which is rinsed out and given for healing or prevention. A lthough non-religious, some Muslim healers use drumming ( ngoma ) for ritual therapy. Janzen (1978: 21) has studied healers and the use of ngoma in central and Southern Africa and explains that ngoma is used for ancestral worship, while divination and healing ( ngoma za kutibu ) are used for healing. The Popular/ Lay Sector Dean (1989:117) defines self-care as the actions that represent the range of behavior undertaken by individu als to promote or restore thei r health. Kleinman (1978) states that in both Western and non-Western so cieties, individuals self-treat 70-90% of health problems in the home. These decisions to self-treat are made by laypersons who face real symptoms and who seek to improve their health without medical supervision. A layperson may choose to delay professional a ssistance until there is failure of home remedies or worsening of symptoms. The utilization of Western pharmaceutical a nd local herbal remedies is widespread in the homes in Mombassa. Ethnicity, soci al class, education and gender play an important role on influencing how home remedies are undertaken. Women and the elderly tend to self-treat more than others. Geissler et al. (2000) found in Western Kenya that the use of home remedies and self treatment starts with primary school aged children, beginning with treatment of minor ailments such as headaches, body pain, coughs and malaria. This is also common in Mombassa. Added to home remedies are the prescription and non-prescription medicines that are receive d from friends and relatives who work in dispensaries or hospitals. With chronic illness, self-medication is at times in conjunction with prescribed medicines. Individuals in a family share and use prescribed medications

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44 without seeing a physician because the treatmen ts are available at home and because it decreases the hassles one has to endure at the local hospitals.

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45 CHAPTER 4 METHODS OF DATA COLLECTION Introduction Methods in social research consist of observing, listening, aski ng and reading. In this study, I used all of these general methods to study the meaning of health behavior among some women in Mombassa. In this chapte r, I explain the specific methods that I used, including a questionnaire and particip ant observation, and how I selected the sample of women I studied. As a native of Mombassa, I encountered some problems in collecting data there, but I also had some advantages. I explain these problems and advantages in this chapter as well. Research Design and Objectives One advantage of being a native of Mombassa is that I already am fluent in the local language, Swahili. I was educated as a nur se in Nairobi and practiced in hospitals there, plus in Mombasa for 6 years before coming to the United States. Over the years I have maintained both family and contacts with in the medical community in both places. I have a few family members in Mombasa, duri ng this research I liv ed with one of my cousins and her family whose residence was in Mwembe Tayari which is in the middle of town. This facilitated easy ambulation around town, and where places were not within walking distance, public transpor tation (or the matatu) was eas ily available. With all of this social support, I was able to conduct this study in six months, from June to November 2003. I used Handwerkers (2001) gu ide on how to perform an efficient and Quick Ethnography, plus Bernard (2002) and Patton (1990) on how to design and

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46 perform fieldwork. During the summer of 2002 I went to Mombassa to reestablish connections with people who would become my key informants, including physicians and nurse-midwives who trained in 1977-1982 when I did my nurse/ midwifery training in Nairobi, Kenya. These gatekeepers became my first informants and helped me to determine what was feasible for my study. They told me which officials to contact when I returned a year later for fieldw ork, and they continued to help me with preparations by email and telephone after I returned to the Unite d States to complete my proposal, develop my initial questionnaires and received Internal Review Board (IRB) approval from the University of Florida. Before leaving th e United States, I as well mapped out a time schedule and structure for data collection. I spent the first two months in Mombas a building a foundation for fieldwork. This consisted of initiating pertinen t conversations, intense listenin g and informal interviews – what Handwerker (2001:106) terms, “first and second order gossip.” During these two months, I also visited official and mapped out interview sites. Data collection and recording, however, was continuous, from the ti me I arrived in Mombassa until the day I left. I started with general, grand-tour que stions, as Spradley (1979) called them: “Tell me about problems that women have here w ith health care?” “Do you have any problems with health care?” and so on. These questions elicited a lot of information very quickly about health issues faced by women in Mombasa and helped me establish clear objectives. My objectives were: 1. to describe Muslim women’s knowledge a nd attitudes about mo ther-to-child HIV transmission 2. to describe the health care decisions made by Muslim women during pregnancy and to identify patterns of behavior in seeking prenatal health care

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47 3. to identify and describe the health care facilities used by Muslim women during pregnancy and childbirth; and 4. to determine the factors that predict whet her Muslim women make adequate use of maternity care in Mombasa. Native Ethnography As a native going home to conduct doctoral research, I had some advantages, but also encountered problems that outsiders would not have experi enced. Clearly, native ethnographers have a more difficult time ma intaining objectivity than would someone coming in fresh from the objectivity than would someone coming in fresh from the outside. I realized as I did this research that there might have been cu ltural patterns that I missed, taking them for granted – patterns that, as Bernard (1996:154) observes, an outsider would see right away. On the othe r hand, as Bernard and Salinas Pedraza say quite explicitly, (1989:5) “all ethnographies are subjective and selective. “The object in social science is not to be devoid of an agenda This is clearly impossible. The object is to maintain standards of data collection that ev entuate in credible work. Anthropologists are enjoined to conduct research from a position of cultural relativism – that is, to avoid making judgments of the cultures we study. “E ach way of life,” we are told, “should be evaluated according to its own standards of right and wrong” (Walbridge and Sievert 2003:2). I duly entered the preliminary stage of my research in 2002 without preconceived ideas about what I would find, but I returned that year with objectives and hypotheses. The participant observation data I collected were verified before leaving Mombasa with key informants for variability and accuracy. On the positive side, being a native of Mo mbasa made it possible for me to conduct this research relatively quickly. I was accepte d quickly by medical service providers as a member of their community and by Muslim women informants as someone with whom

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48 they could speak frankly in their native la nguage, using the kind of idioms and discourse cues that native speakers everywhere rely on for deep communicati on. As a result, I was able quickly to understand the issues that were important to these women. A lot of the nurses express pride in the fact that I wa s studying for an advanced degree, plus impressed that I went back “home” to do th is research. Many stated that once people leave they do not want to get back. The acceptance and cooperation by some of these nurses, particularly Sister Asya (as she was called by most of those who knew her) was particularly important. She took me under her wi ng and introduced me to other clinicians and key people in neighborhoods that I did not know personally or had forgotten about. Sophia, another one of my cousins, helped me establish relationships with traditional birth attendants, herbalists and Islamic h ealers whom Asya did not know. Michrina and Richards (1996:75) observe that “there are tw o types of people in the field, those who are knowledgeable and articulate, and those who can help you make contacts within your group of study.” Asya and Sophia had both of th ese qualities and were invaluable to my research, but the point I want to make here is that my relationship with them was based on the fact that I was one of them – a Muslim woman health-care provider. On the other hand, familiarity also breeds distrust. Concurrently with my study, there was a study going at one hospital on a drug (nevirapine) to reduce mother-to-child HIV infection. I was requested by the nurse in charge of the study not to interview the HIV positive women, because the woman did not want their identity known by anyone who might know them or their families. Other informants agreed to be interviewed, but were clearly uncomfortable and guarded, also not wanting to disclose personal information to someone who might know people in their families. For example, in one

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49 interview with an acquaintance I sensed her di scomfort from the very start when I asked about her marital status. She had heard, sh e said, that her husband had taken a second wife, but had not openly informed her, so she pretended not to know. She hoped, she said, that I would keep this information conf idential since, as long as her husband thought she was not aware of his acti on, she would not have to shar e days with the other wife. (Polygynous marriages are common in Mombasa and co-wives can demand to have the husband share days between households). My fi rst priority, of cour se, was to conduct my work without doing any harm. This meant th at I had to be alert to the need for confidentiality at all times and for keeping informants plus advisors anonymous. Except for some consenting individuals such as Asya and Sophia, pseudonyms replace names of all informants in this study. As I did my fieldwork, I ran into ol d friends and acquain tances. I accepted invitations to weddings, was informed about f unerals and social or religious activities. Most of these events became information grounds for my research and also provided a needed distraction from work. At these f unction with friends I was able to discuss informally various issues surrounding women’s health and particularly preventative care. However, these outings were also a distracti on because of the short time in the field and eventually they became tedious. In addition, I lived in the mi ddle of town with a relative and her family in the neighborhood of the pe ople I was studying. This was perfect as a participant observation field site, although I did not encounter culture shock, there were many changes in Mombasa since I left the islan d. I have lived in the United States for the last twenty years, and although I have gone b ack every other year to visit, these short visits had not prepared me for the changes I would find in my longer stay for fieldwork.

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50 For example, public transportation workers found it strange when I asked them to tell me when I needed to alight at my destinati on. The names of places were the same, but the mode of transportation had changed. Public transportation was no l onger with buses, as had been the case when I lived there ear lier, but with fast moving vans called matatus Of greater significance, despite the many bene fits of native ethn ography, I found myself critically examining my relationship with bot h of my own societies, the one in Mombasa and the one in the United States. Sampling Design My objective was to interview be tween 250–300 Muslim women who had delivered no more than eight weeks prior to the beginning of the study. According to the Kenyan national census, there were approxi mately 48,000 women of reproductive age in Mombasa Island in 1999. Figure 3.1 shows a ma p of Mombasa with 13 areas marked for high concentrations of Muslims and six hea lth care facilities used by Muslim women. I screened potential participants for this st udy at each of the si x facilities and also interviewed some women at home to capture some of the 5% of women who do not deliver at any of the health -care facilities shown in Figur e 4.1. There are three private hospitals in Mombasa. I did not interview at th ese facilities because they are used mostly by women of higher socioeconomic status and who are, therefore, likely to know about and use effectively, all available health-care resources (Enderlein et al. 1994, Ivanov and Flynn 1999, McKinlay and McKinlay 1972). During screening, I sought to maximize va riation in age; ethnicity, education, parity and socio-economic status in order to maximize intra-cultural variation (see Appendix 1 for the full questionnaire). Tabl e 4.1 shows the distribution of the sample across the seven venues. With this purposive sampling strategy, I was able to interview

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51 280 Muslim women who had delivered recently, whether in a hospital or other health facility or at home. Of the 280 interviews, 265 had complete information and consist of women during their six weeks postpartum perio d. These interviews are the subject of the analysis in Chapter 5. Additional informati on gathered during this study has been added to explain women’s health seek ing behavior and add to the qu alitative analysis in Chapter 3 and 6. In addition, I interviewed several clin icians, Islamic healers, traditional healers and birth attendants, and Islamic religi ous leaders (Imams) about Muslim women’s maternity health, particularly in relations to HIV/AIDS. Figure 4-1. Data collection sites 1. Tudor 2. Ziwani 3. Majengo 4. Spaki 5. Kaloleni 6. Bondeni 7. Kilifi 8. Kidogo Basi 9. Kuze 10. Makadara 11. Mwembe Tayari 12. Englani 13. Ganjoni A. Coast General Hospital B. Sayidda Fatima C. MEWA D. Al-Farouk E. Spaki Birthing Center F. Kibokoni Birthing C

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52 Table 4-1. Interview sites Location of data collection Coast General Hospital Number of interviews conducted 50 Sayyida Fatima Hospital 50 MEWA Hospital 50 Al-Farouk Hospital 20 Spaki Maternity Home 20 Kibokoni Maternity Home 20 Home – visits 55 Data Collection Interviews from the questionnaire: The content of my que stionnaire is based on studies of maternity care by Celik and Ho tchkiss (2000) in Turkey, Chapman (1998) in Mozambique, and Magadi et al. (2000) in Kenya. I added questions about knowledge of HIV/AIDS and its prevention. To pretest my que stionnaires, I contacted the owners of the two home-based birthing centers in Mombas a and obtained a list of mothers in the two respective neighborhoods who were clients. I in terviewed ten mothers in their homes and tested the questionnaires. I recited the in formed consent protocol to each pretest participant in Kiswahili, and each of them a nd received their permission to continue with the understanding that I would hol d their information in confid ence. After ten interviews, I learned what worked in the questionnaire and what needed rewording. I wrote the questionnaire in English and translated it into Kiswahili, taking care to frame the questions properly in the local idiom. For example, the question “did anybody help you decide when to start prenatal care?” a direct translation would sound curt and provide a

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53 yes or no answer. This would have to be followed with “whom?” However, rephrasing it by asking, “mshauri wako ni nani ukitaka kw enda kupima?” (“Who assisted you in the decision to prenatal care?), would provide bot h answers. A few of the respondents that I pretested the questionnaire on were uncoopera tive, giving short, abrupt answers; some were reticent because they felt embarrassed by the questions, while others were verbose. After correcting the que stionnaire (see Appendix D), majo rity of the respondents were very cooperative. I controlle d the interviews by leading and providing the appropriate verbal and non-verbal feedback. Structured interviews: The questionnaire consisted of structured and semistructured interviews. The structured com ponent comprised a series of items on sociodemographic features, and some questions on the availability of medical insurance. Marital status – a socio-demographic feature that usually elicits a simple answer – was quite complicated. During the pretest, I f ound that some women hesitated to answer a query about their marital status and would not affirm or de ny whether they were in a monogamous or polygynous relationship. On e woman responded: “How would I know?,Maybe I am the only wife, and maybe I am not.” Thus, in addition to the usual “yes” and “no” answers for this question, I wrote side notes to include women’s added responses. The question on occupational status also caused some diffi culty. A number of women initially said that they were hous ewives, or provided one occupation. However, with time I noticed some were involved in different trading practi ces from the home. I reworded the question to include women’s activities or jobs that supplement their income.

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54 Education, both secular and religious, is an area of great concern to the women I interviewed. They voiced their frustration at not being able to continue with their schooling because of cultural or religious restricti ons, either as understood by them or as imposed by their families. Other components of the structured questi onnaire included educ ation (both secular and religious) of the spouse or partner, spouse’s occupation, and whether the spouse or partner was employed in Mombasa or resides elsewhere (approximately 15% of partners in this study live or work for prolonged pe riods out of Mombasa) I also asked about whether the partner ha d medical insurance. Finally, I assessed socioeconomic status with data about the status of the home. I asked whether a woman owned or rented th e home she lived in; whether the home had electricity; and the source of water for the home. There were three sources of water: tap water (from indoor plumbing), well water, and water bought from an outside source. I observed women spending a lot of their day either collecting water or waiting for someone to deliver water. Piped water in Ke nya is state controlled, and when there is a shortage, it is rationed to certain hours of the day. Water is sold from state-run neighborhood stations that open from 6 a.m. to 5p.m. For a payment of a few Kenyan shillings (Ksh.) 25 which is about U.S. 32 cen ts, water can be delivered to one’s home, but if the deliverer is busy, waiting for wa ter delivery could use up the whole day. The house I lived in used well water for every ot her need, except drinki ng and drinking water was bought twice a week. I had the experience of wasting mo st of a day waiting for drinking water to be delivered. I understood when women complained and stated their frustrations about access to water an d their relief when water arrived.

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55 Finally, a section of the structure was a bout women’s awareness of how HIV might be transmitted from mother to child. If a woman said that she knew the manner of transmission, then the next question was a bout the source of her knowledge: word of mouth, school or college, a heal th care provider, or the medi a (television, newspapers, or radio). A follow-up questi on probed whether the woma n thought her knowledge had changed her behavior. I asse ssed behavioral change by as king if the women had been tested for HIV, and if the test was positive, if she had delivered in a medical facility that offered procedures to prevent passing the in fection to the infant. Although this last question was placed under the structured inte rviews, it could as well belong to the semistructured section. Semi-structured interviews: The semi structured component of the survey dealt with women’s pregnancy and childbirth expe riences. These experiences are private and personal and were embellished and dramatized or downplayed, depending on each woman’s circumstances and perception of those circumstances. I was able to interview each woman only once and allotted up to two hours for each interview. I was, however, sometimes unable to complete the work in th is time. Some of the narratives were joyous, but the heartrending experiences of others were so emotionally wearing, on me as well as on the narrators, that we often had to take breaks in the middle of the interviews. Some women had complicated pregnanc ies and were strong narrators, while others were first time mothers without complications. This, t oo, played a role in how much time was needed to complete each interview. During the open-ended narratives, women expressed their relief or frustrations about pregnanc y and childbirth and mentioned people who had

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56 participated in their journey to motherhood, including partners, family members, friends, neighbors or health care providers. In this section of the su rvey, I also developed pre gnancy histories: number of children, miscarriages, abortions and stillbirths. I felt that many respondents answered these questions truthfully, except the questi on about abortions. Abor tion is illegal in Kenya and it is forbidden in Islam, but it is widely known that Kenya has a high rate of unwanted pregnancies that lead to abortion (Bauni and Jara bi, 2000). One of the leading causes of hospitalization in Kenya in 19991 was admissions after abortions. Data on abortion prevalence between provinces s howed the Coastal province (including Mombasa) had lower rates of number of ad missions than all othe r provinces in the country (Ministry of Health Report 1996-1999). I inquired about the date of conception, when and where prenatal care was started or continued, and who assisted or impeded these decisions. I aske d about transportation to and from the clinic and wh ether the woman liked or did no t like the health care center or provider. Women had a lot to say about the health care sy stem (see Chapter 5). In this final section, I explored hea lth care decisions – that is wh ere, when and why respondents had begun treatment when sick during the pregnancy. Answers provided were further probed for diagnosis given, length of treatment and effectiveness. I was able to extract from these data a taxonomy of the major illne sses or problems that are associated with pregnancy, the type of healer used, and a description of the treatments The main conditions that were consistently mentioned were homa (fever); anemia; shango (vaginal discharge), possibly due to f ungal or bacterial infection; body aches and pains; and 1 The updated Ministry of Health re port for the years 2000-2003 were not published while I was collecting this data.

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57 mwajuu with some symptoms that resemble hi gh blood pressure in pregnancy. Some of these names of illnesses, such as mwajuu and shango were unfamiliar to me, despite having practiced nursemidwifery in Momb asa from 1982 to 1983. I was also unfamiliar with some of the treatments for illnesses that were mentioned, including some home remedies, some traditional and Islamic healing practices, and even some treatments used among various ethnic groups living in Mombasa. “Even the most experienced of ‘native’ anthropologists,” said Narayan (1993:683) about her ethnography in India, “cannot know everything about his or her society.” The Research sites As shown in Table 4.1, I did participant observation at four hospitals, two homebased birthing centers, and visits to mother s in their homes. In the hospitals (Coast General, MEWA, Sayyida Fatima and al-Farou k), I observed women as they came to clinics at three different stages: (1) fo r prenatal check ups, (2) during postpartum assessment, and (3) when they brought their infants for the six-week post-delivery evaluation. The second and third stages were logistically feas ible; for this study. Coast General Hospital – the waiting room: At Coast General, women brought their babies for a six-week post-delivery checkup on Mondays, Wednesdays and Fridays between 8a.m. to 1p.m. These hours were hos pital policy and were rigidly enforced. Women who came late did not fi nd a clerk to give them a ch eck-in card or see a health care provider. The benches were full by 7a.m. and a quick hustle ensued to the clerk’s desk as he sat. First, women had to regist er their babies into the hospital system and receive a patient number. Next, they had to pay for services in another room. Then, women waited in a second line for a nurse to check the baby’s weight and temperature and assign them a room or cubicle to see a clinician. This process, including the checkup

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58 by the clinician, took from three to five hours. Many women grumbled and expressed frustration or sighs of resigna tion during the course of a nor mal day at the clinic. Some infants cried while others were continuously breast, or bottle-fed. Mothers changed diapers while waiting to be seen. I found a quiet corner and called mothers aside for interviewing. I asked the other mothers to re serve the informant’s space in line, so that she would not miss her turn to be seen by a clinician. During these moments, I had the opportunity to listen and obser ve the interaction between the women, the health care providers and other hospital personnel. This waiting to be seen by a clinician was for well and sick babies and there was constant commotion as women moved from one area to the next. The whole area was open except for walled partitions. Once, a mother began wailing as her child died in her arms, waiting to be seen. I learned later from the matron-administrator of the clinic that women were supposed to take very sick in fants to the emergency room. This was not something that was widely known or understood. In fact, I had to ask about this incident to find out that it was possible for mothers wi th very sick infants to get quick treatment. This event was so distressing to me that I st opped interviews for the day and went home. Coast General Hospital – the postpartum ward: This is part of the maternity floor where women stay to recover after childbirth. Women stay for 2-5 days postdelivery if there are no complications and leav e after payment for hospital services. Some are being given medication intravenously a nd some require blood transfusions due to complication in delivery. Other women are well enough to walk around to visit each other, or go back and forth to the toilet. In fants are either aslee p, breastfeeding or having their diapers changed in this area. The r oom was quiet, except for an occasional nurse

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59 passing by on errands. I spent the mornings in the mother/baby clin ic, and afternoons and evenings conducting interviews in the post-pa rtum area. I left during visiting hours to allow family and friends to visit. I would i nquire from the nursing staff which patients not to disturb before interviewing. MEWA / Sayyida Fatima and Al-Farouk hospitals : These hospitals were designed to cater to a Muslim clientele. Although the administra tors and health care providers are Muslims, less than 15% of re spondents stated that they chose these institutions for religious reasons. As I w ill explain in the following chapter, these hospitals were mostly chosen because of dist ance, cost, and the avai lability of specific services. As with Coast General, I conducted inte rviews with mothers who brought their infants for a well-baby check after six weeks and in the postpartum ward. Compared with Coast General, service at these two Muslim hospitals was much quicker. The average waiting period was about an hour and all proce dures were done in th e room with a nurse, though a physician saw patients when necessary. I asked to conduct interviews with the women before they left th e hospital. I also spent ti me here observing how women interacted with each other and with health care providers. I noticed that unlike the other government clinics prenatal classes were not offered, and women left quickly after receiving services. In fact, I had a hard time getting some women to stay for interviews. Overall, though, I was able to interview most of the women who I approached. One reason for my success, according to other nurse s at these two hospitals was that I dressed in a bui bui or abaya, the black overcoat and scarf worn by almost all Muslim women in Mombasa. Had I dressed as hospital personnel women hurrying to leave after being seen

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60 would not have been as ready to linger and sit for an interview. My dress as a Muslim woman was a cultural asset and helped me to develop rapport with potential informants (see Warren and Hackney (2000:22) for more on the importance of dress in fieldwork). Time spent in the hospitals helped me develop close relationships with the clinicians. In one institution, I was asked to assist with deliveries when the hospital was short staffed. This would have allowed me to move entirely into the role of full participant as observer, but I declined po litely and disengaged in order to maintain a different relationship with patien ts than that of the staff. I opted for more detachment and less engagement, as Hayano calls it (1979:113) Balancing multiple identities as nurse, native and researcher was a constant in this study. Opting for a more engaged role as a clinician might have produced more data, or different data, of course, than those I was able to collect. Spaki and Kibokoni maternity homes: In these two biomedical facilities, women were observed as they came in for prenatal or postpartum visits. Others brought male infants for circumcision, or pregnancy relate d problems. Deliveries ranged from one to two a day, recitations from the Koran was done while the women were in labor, and women were also encouraged to recite from th e Koran in order to distract them from the pain and provide spiritual comfort. I asked women specifically why they had chosen to use these maternity centers. The environmen t was relaxed and jovial, and if the women had not stated their specific reasons for co ming, one might assume they were there for a friendly social visit. I did twenty interviews at each of these two homes and five more in each neighborhood to get opinions about these homes from women who did not use them. I also interviewed the nurse, the assistant and the surgic al technician about their

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61 techniques and their rappor t with the people they serv ed. With my knowledge as a clinician, I could not help but judge the care given to women. One of the two maternity homes did not have a full-time qualified practi tioner, and some of the decisions of the practitioner on hand were not reassuring. Once, when a woman came in complaining of premature labor, she was not referred to a hos pital where she could receive urgent care. Instead the patient was massaged and sent hom e. I provided general suggestions in my discussions with the practitione r as we compared notes abou t different ways to assist women and improve their heal th care in various conditi ons, but I did not intervene directly with nursing or medical given. Mama Msena and Bi Zuena – Traditional birth attendants In comparison to the home-based maternity clinics, where there was a semblance of biomedical influence, these homes were regular liv ing arrangements with a room assigned for assisting in childbirth. The term for one who assists with childbirth is mkunga or mpokeaji which translates as “one who receive s” or assists. Both women we re warm, motherly and were referred to as ‘mother’, ‘aunty’ or ‘grandmother’ by their client s, as if these traditional birth attendants were members of the clients’ families. As I visited these homes, I realized they were not only used for childbirth, but for advice on child rearing (particularly of daughters) and for counsel on marital relations. It was definitely a women’s domain. Men who stopped in we re on errands for their wives. The birthing rooms in both homes were empty, except for a bed with a thin mattress, covered in plastic, and a pillow. Th e patient had to bring her own wraps, or khangas which are colorful rectangular cloths, 1 by 3 yards in width and length. These khangas had multiple purposes and were used as a bed covering, or as a body wrap while

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62 the woman was in labor, or to cover the baby before going home. Women who came to deliver were also instructed to bring their own surgical gloves (a recent practice that has been encouraged since the advent of HIV/AI DS), cotton balls, a blade, tie string, and disinfectant. Mama Msena kept her medicinal remedies in the courtyard, where she also had a variety of herbs, and medicinal plants. She was peti te, quick witted and full of humor. Many women in the neighborhoods acr oss Mombasa mentioned her name as I conducted interviews. Mama Msena lived on th e outskirts of Mombasa, but women came to see her for different ailments, particularly infertility. Women stated that they respected her because of confidential ity and generosity. Women came in for massage therapy, particularly after delivery, and interviews were conducted after their visits in the courtyard or by following women to their homes. Women went to Bi Zuena for different reasons. She had worked in a hospital as a clerk, before becoming a traditional birth attendant (TBA). She did not indulge in herbal healing, although she performed massages. She stated that she was conducting less childbirth deliveries with the intention to discontinue the practi ce. One of the main differences between these homes and the bi omedical facilities were the one-on-one rapport between care-giver and patient. About th irty percent of women in this study used home-based maternity services. From my in terviews with these women, they understood the dangers that this choice involved, should an emergency arise during delivery, but they chose to overlook those dangers. I will revisit this issue in Chapter 6. Some women who could afford the other biomedi cal facilities still attended the services of the TBA and other healers for home remedies and massage therapy.

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63 Traditional Healers: I reached the Majengo market as directed to meet Bi Riziki, a healer. I had been informed she had expe rtise in treating probl ems associated with pregnancy. After crossing rainwater-filled po tholes on the path, and dodging human and automobile traffic, I arrived at the entrance to the market. I asked for Bi Riziki and was directed to her stall. She was standing by a sh elf filled with a variety of herbs, roots and some form of vegetation. Her son and also assistant was welcoming, but she looked at me suspiciously, particularly when she saw I ha d a tape-recorder and camera. I assured her that I was not going to use them without he r permission. She relaxe d temporarily, but was on guard throughout this initial visit. I refrai ned from asking her or her clients questions and instead observed thei r activities. On future visits, she calmed down, and I was able to interview her and some of her female clients. She even allowed me to audio tape her and take pictures, something I had not been able to do throughout this study. Women came to Bi Riziki with complaints of gynecological and obstetrical problems. At times, she walked away with them from the stall, for privacy, something that I also imitated when I interviewed one of her female clients. Wome n also brought their partners and infants for consultation. The second healer Bi ZamZam was from a different ethnic group from Bi Riziki. She was more relaxed, and had no reservati on in explaining her different types of remedies. Women came to her mostly for treatm ent of anemia and for massage therapy. She referred some of her patients to Bi Riziki and the hospitals when the ailments were beyond her scope of treatment. Home visits – “Are you an American spy?”: Conducting home visits was the most difficult part of the data collection. I in itially wanted to inte rview women in their

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64 last month of pregnancy and do a follow up vi sit after they delivered. This proved to be impossible because most women (especially those unemployed) moved to their mother’s or in-laws’ house for the forty days after delivery. This is a cult ural practice called arubaini (forty days) to help the mother and baby recupera te after the strain of labor. The woman is considered unclean after childbirt h, and is excused from household duties, until after the forty days. The practice of arubaini varies in Mombasa’s different ethnicities and economic status. I will retu rn to this issue and how it a ffects the use of health care services in Chapter 3. To find women whom I might interview in their homes, I walked door to door through the neighborhoods mentioned in Figure 4.1 to inquire if there were any women in arubaini These neighborhoods are densely populate d, with houses very close to one another, and people are involved in each other’s affairs. This made it easy to find mothers in arubaini. On the other hand, home visits were ti me consuming, because it was difficult to enter and exit immediately af ter an interview. Some peopl e wanted to get to know me and my work, and asked about life in Amer ica. I developed a s hort and uninteresting narrative that I kept repeati ng and that would not prolong my stay. Most of the homes consisted of extended families or had visito rs to see the mother and new baby. One-toone interviews were difficult to conduct, w ith a lot of chit-chat before and during the interview I avoided late evenings in order not to interrupt meal and family times. I also excused myself when partners arrived home. I did this for two reasons. First, I understood the culturally appropriate gender roles. Wome n are expected to cater to their partners when the latter arrive home. Second, while I encountered few men during this study, those whom I did meet were suspicious and questioned me about my research,

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65 particularly when I mentioned that I was associ ated with a university in the United States. This suspicion from men made the women uncomfortable and I knew that under these circumstances, their answers to my questions would be inhibited. The suspicion among men reflected anti-Am erica sentiments in Mombasa. The American invasion of Iraq star ted in March 2003 and I started home visits in August of the same year. Various groups of Muslims in Mombasa, particularly young men, had demonstrated against American involvement in Iraq. There was plausible suspicion that some Muslims were involved in the Al Qaeda movement, which resulted in a joint effort by American and Kenyan intelligence services to search Muslim homes in Mombasa. This created an ambience of distrust and I was at times asked by men, during my home visits: “are you an American spy?” or “ how do we know that you were not sent to investigate about terrorism?” The women did not question me, but once their partner had created an air of distrust, women became wa ry and their answers to questions became cautious. Warren and Hackney (2000: 17-19) ob serve that anthropologists have been considered as spies from the United Stat es government everywhere they have done ethnography. They add, however, that men are mo re likely to be suspected of being spies and indeed, in Mombasa I felt I was regarded with less mistrust because I was a woman. Being a woman, I was perceived as having less power, and therefore not dangerous. These interviews of Muslim women in Mombasa about their pregnancies and childbirth experiences were, at times, catha rtic. I found it hard to remain uninvolved, emotionally, and to focus on data collection, but I did not let the need for objectivity stop me from answering questions from my inform ants or assisting them with information about women’s or infant’s health, care of infants, breast feeding, mixed feeding, and so

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66 on. Women disclosed their health problems to me and I provid ed advice within the scope of my knowledge as a nurse practitioner. So me of my advice was practical, such as how to position infants and prevent nipple soreness or breast engorgement. At times my advice turned out to be impractical. For exam ple, I counseled women to use canned infant formula instead of diluting cow milk for feed ing newborns. I later learned the difference in cost. My twenty years’ experience as a nurse and midwife helped me establish strong rapport with my informants. There was a cost to this, as well as a benefit, for with that rapport I heard many stories of pain and suffering. Statistical methods The data from the 265 structured and semi -structured interviews were analyzed using SAS and SPSS. The questionnaires and co debooks for the structured interviews are in Appendix 1. There are two dependent variables in this study, both of which involve the use of maternity health care services. One is the use of prenatal care and the other is choice of a birthing center. Since the de pendent variables are binary, I used a logistic regression model to estimate the probability of wome n’s behavioral choices given a series of independent variables. The narrative data were analyzed with the help of Atlas/ti (scientific software – version 4.1). Analysis of women’s narratives about their use of maternity health provides insight not obtained from the quantitative analysis.

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67 CHAPTER 5 RESULTS FROM THE DATA ANALYSIS Introduction This chapter presents selected results from the structured interviews. The individual respondent’s questionnaires pr ovided information on the following: socio-demographic characteristics, household characteris tics, knowledge of mother-to-child HIV transmission, and the seeking/ utilizing of maternity health care. In answering the question, “what factors impede or provide access to maternity health care?” I created a number of variables, guided by the literat ure, about how women make health care decisions. Any individual decision can be driv en by more than one factor. For example, a woman might have health care insurance (which would allow her to deliver at a hospital at no cost), but decide to de liver at a home-based maternit y facility for some personal reason (like not wanting to be probed clinically by strangers Analysis Since the two dependent vari ables are binary, I apply l ogistic regression. (Logistic regression estimates the probability that th e qualitative dependent variable has two possible outcomes [Allison 1999:19, Agresti and Finlay 1997:575]). The dependent variables are: 1. Did the informant get prenatal care (yes/no) 2. Did the informant use a birthing center (yes/no) I used stepwise selection to determine the fi nal list of explanator y variables in each model. Considering the sample size, I include d variables that were significant up to the

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68 0.1 level. The results of this exploration for the two models are shown in Tables 5-5 and 5-6. In Model 1 (Table A-5) the informant attr ibutes with statistical significance are education, partner’s Islamic education, telephone ownership, knowledge of HIV transmission (in utero) a nd number of miscarriages. In Model 2 (Table A-6) informant attributes with statistical significance are ethnicity, health care insurance, respondent’s educa tion, test for HIV, knowledge of MTCT(in utero), previous childbirth, education and HIV test and previous ch ildbirth and HIV test. The reasons explored for us ing prenatal care or for a particular birthing center were: the fact that the institution followed Islamic practice, distance, the presence of health care providers, cost, the presence of services and a woman’s particular health problems. Tables A-5 and A-6 show the p-va lues and odds ratios for the nature and strength of association between the dependent and these explanatory variables. In Model 1 explanatory variables with statistical significance were distance and health care services. In Model 2, distance, health care provi ders and cost had sta tistical significance. Section A – Socio Demographic Characteristics Age: As indicated in Table A-1, the responde nt’s ages averaged 26, with a range of 16-47 years. Across the world, women younger than 20 or older than 35 experience more obstetrical complications than do women between 24 and 34. Although not statistically significant, younger women in my sample use health care services less, particularly with their first pregnancy, although more deliver in a biomedical facility. As well, lower socioeconomic status and lack of social support mean that younger women have less access to health care than olde r women. On the other hand, women who have more than two children use prenatal care less an d take time before going to a facility to

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69 give birth if they do decide to go at all. This relaxed att itude stems from experience of previous childbirths. Ethnicity: The largest ethnic group in Mombas a is the Mijikenda, who comprise 30% of my sample (N=80). The second larges t group in my sample, at 27% (N=70) are self-identified Arabs. Only 5% (N=14) stated they were Waswahili. Ethnic affiliation is fluid in Kenya – “situational, rational and changeable,” as Cooper (2000:120) says. This has long created confusion in Kenya, particul arly during census coll ection ((Republic of Kenya: Census 2001). For example, people of the East African coast, particularly those of mixed ancestry such as Arab/African or Asia n/African, are all identified as the Waswahili by the Kenyan government (Middleton 1992). Ho wever, women categorize themselves differently from how they are labeled. Ethnicity does not play a role in seeking prenatal care (Model 1) but it plays a ve ry significant role (p< 0.0001) in the choice of a birthing facility (Model 2). There was higher probabi lity that Arabs, Asians and some Waswahili will choose biomedical childbi rth facilities than the ot her ethnicities because of affordability (0R= 12.17) (Table A-6). Marginalized ethnic groups use health care differently from the dominant groups in so cieties. In observation as well, childbirth assistance by a TBA was more common among the Mijikenda, Bajuni, Jomvu, and Changamwe. In Mombasa, historically, the Arabs, Asians and some Swahilis, have had resources deprived of the Mijikenda and ot her smaller groups (Mkangi 1995). This has been shown as well in various other studies outside Africa, for example in Britain, Petrou and colleagues (2001) infer that women of Pakistani and Indian origin made fewer prenatal care visits than white British women. This above study claims cultural and religious beliefs as plausible factors to d ecreased attendance. Similar studies in the

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70 United States have indicated that African -American, Mexican-American and PuertoRican women do not adequately use maternity health care (Echavarria and Parker 2001, Gardener et al 1996, McCaw-Bi nns et al 1995, Lia-Hoagberg et al 1990, Petitti et al 1990). These studies stated that socio-economic status plays a role in access to health care services leading to poor ma ternal/child health outcomes. Education: Respondent’s education is highly sign ificant in both models, use of prenatal care (p=.001) and in choice of childbirth center (p=. 02). There is a high correlation between education and better h ealth care. On evaluating respondent’s education, about (N=31) 12% of women ha d never been to school (see Figure A-2). Reasons for not attending school varied, the most consistent was inability to afford schooling. Although school attendance had been free for this population, parents still had to pay for uniforms and school supplies. Th e above 12% estimate of Mombasa Island alone was slightly higher than the whole dist rict’s estimate which was 8%. However, it is lower in comparison to the country’s estimat e which is 35% (Republic of Kenya: Census 2001). More than half of the respondents (N=142) 54% had elementary or primary education. The numbers decreased with sec ondary education to (N=89) 34% and only two women had a college degree. The probability of use of a biomedical facility increases when the woman or spouse have higher education and subsequently increased socioeconomic status. The odds of using a biomedical facility increased as women’s educational level increased (OR = 0.11) (Table A-5) and (OR=0.01) (Table A-6) Although education was a factor another component that was obvious on observati on was respondent’s economic status. According to literature, women’s access to reso urces, including health care increases as

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71 their personal socioeconomic status rises independent of their spouses and children (Handwerker 1989). Assessing women’s socioe conomic status was difficult because women downplayed what they did both in trade schools as well as outside the home. More than half of the respondents (N=139) 53% stated that they we re “only” housewives. Nevertheless, I observed the majority of women involved in many different home-based trades. These jobs consisted of selling jewelry, cloth mate rial, fried potatoes, frozen lollipops, and even selling wate r. Some women claimed that th ey were in sales, (N=56) 21%, they sold items door to door or to shopkeepers. Islamic education: In Mombasa, Islamic education is started before secular education and is not entirely free. Only 17 of the women (6%) had no Islamic schooling. These few women were either recent convert s or had parents who could not afford the cost of Islamic education. Muslim clerics charge about 50-200 Kenyan shillings (about one to three U.S. dollars) per month to t each Quranic classes. Sixty-three of the 146 women who had completed grade school said th at they were continuing their education. Women in this group also reported meeti ng with others for other non-religious discussions, such as issues involving the community, health, edu cation and politics. Several of the women in this group were e ducators, conducting classes from home or involved with madrasas Islamic education was not statistically significant in either of the two models. Marital status and union: The overwhelming majority of the respondents were married (N=257, 97%). Women wh o reported being separated or divorced stated that the breakup of their marriage had occurred while they were pregnant. There was only one unmarried woman and two women cohabiti ng under a common law relationship. Five

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72 women stated that they had left their marita l homes to go to their parents’ homes after childbirth and had not gone back. Among those married, approximately 87% (228) stated they were in a monogamous relationship, while about 11% (29) reported being in a polygynous relationship. Some women in polygynous unions stated that their husbands alternated households, dividing his days am ong the wives. This could, they reported, change in late pregnancy, where the husband had to be availabl e in case the wife went into labor. Only one respondent stated she delivered at home, having been delayed in going to the hospital while waiting for the husband to return from the other wife’s home The majority of the respondents were married (N=257) 97%. There was only one unmarried and two cohabiting under common law relationshi p. Women, who declared separation or divorced, stated that the separa tion or divorce had occurred wh ile they were pregnant or during their postpartum period. Five women stated that they le ft their marital homes to go to their parents’ homes after ch ildbirth and have not gone back. Section B – Household Characteristics Health care advocates: According to the health care access literature as discussed in Chapter 1, support from spouse, family or friends plays a role in how women use biomedical health care. In this study, women’s supporters and social network was assessed through investigation of the house hold characteristics (see Table A-2). Spouse’s education: Men had more formal education than did their partners. Male partners without formal education we re (N=4) 2%, and elementary education was about (N=85) 32%. The numbers with a s econdary education were (N=153) 58%, and (N=11) 4% had a college degree. Trade schools were attended during and/or after secondary schooling. Although spouse’s secula r education did not have statistical

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73 significance in the logistic regression models, educated men were more supportive of their wife’s use of biomed ical health care (OR=0.23). Partners with an Islamic education encour aged their wives more to use biomedical prenatal care (p=.07). Spouses with seconda ry secular education also had advanced Islamic schooling. Spouse’s occupation: Partner’s education and occ upation played an important role in affordability of health care. A pproximately (N=66) 25% of the respondent’s spouses were drivers. Drivers in Mombasa ope rate private public transportation or vans called matatus. The matatus transport commuters within the island for a minimal amount. Other drivers moreover, transported goods from the island inland to other parts of Kenya, or to other countries, such as Uganda a nd Congo. Approximately 35% of partners work out of the country, and visit their wives in Mombasa after a few months, a year or even after two years. Their wives stated that these visits lasted a month or two. Researchers at the Coast General Hospital reported that, they had observed that the majority of their HIV positive women had spouses who were drivers, both local and long distance. Extensive research on the spread of HIV among truck drivers has been conduc ted in Africa. These studies explain men’s high risk sexual behaviors with prost itutes at truck stops to and from their destinations (Rakwar et al. 1999, Nzyuko et al. 1997). Other occupations included cl erical office workers (N=46) 17%. Involvement in the local tourism business, either on a full-time or part-time basis was explained as a major source of income. Odd jobs to supplement income were explained as a survival approach needed at a time of infl ation and a poor economy.

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74 Adults in the household: The number of people in the household played a role in the acquisition of health care. The major ity of the respondent s lived in nuclear households (N=169, 64%). About a third (N=87, 33 %,) had in their households three or more family members that is extended famil y. In the survey there were some respondents who reported living with shari ng the household with many in-l aws, up to four brothersin-laws and their wives. Advice and decisions about health care in such households was complicated. As stated by one respondent, “I ask my husband where to go for prenatal care; however my fellow sister s-in-law also help me make decisions. But our mother-inlaw has to approve before a final decision is made” More than half of the respondents (N =136, 51%) stated they consulted their husbands on when or where to initiate pren atal care and choice of a birthing center. A few (N=39, 15%) made their own decisions, while the remainder consulted their mothers, in-laws, or friends. Women who lived with their in-laws stated that they felt obligated to seek advice from their in-laws before making final deci sions concerning health care. One respondent said, “after all I now live with them, they are like my parents. I have to include them in all decisions”. On a few occasions, women complained that their mother or sist er-in-laws were not as sympathetic as their own female kin. One informant protested, “My mother-in-law left me in labor for two days before my mother cam e to escort me to th e hospital”. I observed that a majority of women’s mothers were i nvolved in caring for their daughters while in labor and after childbirth, nonetheless the hus band and his family had the final word on decisions.

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75 Medical Insurance: Respondent’s with medical in surance comprised a quarter of the participants (N=69 26%). Availabi lity of insurance had marked statistical significance (p = .0008) in Mode l 2. Women with higher income (whether their own or from spouse/family) were more likely to have medical coverage than were those with lower incomes. Medically insured women had access to biomedical prenatal care facilities and could afford to deliver at hospitals (OR=0.28). Even so, a few such respondents complained that they did not us e private hospitals. So me said that the majority of the hospitals demanded user fees before rendering services. The government run national hospital insura nce fund (NHIF) was not trusted by many hospital accountants and physicians for timely reimburseme nt. Respondents also asserted that the NHIF and other insurance companies took t oo much time to reimburse them. Employer sponsored private health insurance for work ers were one of the primary sources of coverage. Among the private sector firms, em ployers that offered insurance had varying premiums by industry. Respondent’s reported th at the majority of the employers of many firms either did not offer or c ould not afford to contribute to the premiums. Most of the uninsured did not have regular doctors, and mo ved from provider to provider in search of affordable health care. Water availability: Mombasa suffers many of the problems one finds in most third world cities. The town’s growth preceded the establishment of a solid, diversified economic base to support housing and other infr astructure. Piped water, electricity and sanitation are still inadequate and women spend a lot of their time getting water for daily use. Although water was not statistically sign ificant in Model 2, it was a major component in health care and a time-consum ing commodity when not easily available.

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76 Unsafe water carries diseases, including typhoi d, cholera, hepatitis, dysentery, amoebiasis and intestinal protozoa. Approximately one-t hird of the respondents had complained of suffering from typhoid while pregnant I will discuss this issue fu rther in the next chapter. Electricity: The vast majority of the respondents (N=244, 92%) affirmed having electricity. Power outages, however, are common in order to conserve fuel. For people who have wells and water pumps, lack of electri city meant lack of power to extract water. Women had to time the availability of electricity so that they could be home to fill water into buckets or plastic cylindr ical bins for later use. At times the period of no water or electricity was announced on the radio, at times not. I observed quite a few births when there was no electricity; attendants used kerosene lamps, flash lights or candles The approximate eight percent who stated they did not have electricity had complaints about the power and lighting co mpany not being efficient in reconnecting electricity after disconnection. Car ownership: Thirty-three (12.5%) women stated they had a car, but cars (or lack of it) were important for all women when they needed to go to the hospital in a hurry. A couple of home births occurred due to lack of transportation to take a woman to the hospital. Car possession whether private or of companies were requested to transport neighbors and friends to and from the hospita l. Doing favors to transport the sick to hospital was an everyday occurrence. Telephone ownership: In the questionnaire, (N=175, 66%) of women reported they had mobile telephones. Telephone owners hip was a significant (p = .01) predictor of a woman’s using prenatal care services (OR=0.16). Some women stated they would rather be without other household necessi ties but have enough mi nutes on their phones.

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77 Even street vendors who could barely r ead or write had mobile phones. A few interviewees who reported not having a phone stated that th eir husband or other family member in the household had one. Respondents with phones used them to inqui re about health care providers and services from others who have been to them Some women reported going to a clinic and being told to return another day because the blood pressure machine or the hemoglobin testing instrument was not wo rking. Women who had mobile phones said that they would call ahead and make sure that there was a physician on duty or that certain services could be performed. Telephone possession also increa sed convenience in making arrangements with relatives, friends or business acquaint ances, providing time to attend the clinic for prenatal care. Mobile phones are not cheap. However, as the numbers indicate, women value their phones greatly. Section C – Knowledge of Mother-t o-Child HIV Transmission (MTCT) The Kenyan government in conjunction with world health bodies has done major campaigns to promote HIV/AIDS prevention and transmission. The vast majority of respondents (N=249, 94%) stated their awareness of MTCT Less than five percent acknowledged being uncertain of modes of transmission, while less than two percent declared being completely unaware (see Table A-3). Also, the vast majority of women (N= 245, 93%) (Figure A-3) confirmed that the media was their main source of informati on. While conducting this study, I heard daily public service announcements about HIV tr ansmission, informing the public on the importance of prenatal care and the possibi lity of MTCT. Information about HIV/AIDS was also present in the ne wspapers almost daily.

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78 Women could check more than one source of information for this question and health care providers were listed by 113 res pondents (43%). Various clinics held teaching sessions with prenatal care attendees and informed them about MTCT. Posters were evident in almost all clinics and hospitals. In addition, women aged 16-25 reporte d getting information about HIV transmission from schools. A few of these respondents stated that they belonged to HIV/AIDS advocacy groups initiated from high school. Only 41 women (16%) acknowledged open or informal discussions about HIV awareness, let alone MTCT. Indeed, open disc ussions about HIV spread and prevention were never without reservations—such is the stigma and shame attached to the disease. Many women who are aware of MTCT are awar e all three modes of transmission: in utero (N=207, 78%), during childbirth (N= 185, 70%) and while breastfeeding (N=160. 60%). Women’s response regard ing MTCT in utero was sign ificant (p=.03) in Model 1. Similarly, in Model 2, (p=.0001) the probability of a woman attending or delivering in a biomedical birthing center increased if aw are that she was HIV positive (OR=0.19)(Table A-5) and (OR=0.22)(Table A-6). Though radi o messages educated the public on the importance of prenatal care and HIV test ing while pregnant, the messages were not specific about the three modes of transmi ssion. Respondents may have been aware of transmission during childbirth, but they did not say that it was important enough for them to deliver in a level 2 or 3 hospital where there can be MTCT prevention. Prenatal HIV testing: Prenatal HIV testing an d screening has been recommended for every pregnant woman by the World Health Organization. Over 70% of respondents reported being tested for HIV were (N=189). HI V testing was highly

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79 significant (p=.01) in the model for choice of a birthing center. The combination of increased education and having been tested for HIV is signi ficant in the model (p=.03) (OR=1.11). That is, women who had increased secular education and had an HIV test chose a biomedical birthing center. In this study there was no confirmation wh ether those tested went back for results, or whether the results were positive or negati ve. However, according to the literature, and from my own observation, the majority of women tested for HIV do not go back for results. In addition, lack of follow-through, pa rticularly in a poorly established health care infrastructure, leads to lack of counse ling, diagnosis, and treatm ent for those how are HIV-positive. This was evident in both th e clinics and hospitals in Mombasa. Obstetrical Characteristics Number of children or parity: Previous childbirth experiences both good and bad played a role in how women accessed mate rnity health care. Women with previous childbirth formed the majori ty of the respondents at (N =166) 63%. There was marked significance (p=.0001) in previous childbirth and choice of a birthing center, but not in use of a prenatal care facilit y. First time mothers, plus women who have had more than five pregnancies are associated with usi ng non-biomedical facilities (OR=0.29). First time mothers mostly belong in the younger age group of 16-25, have lower socioeconomic status, and at times lack the sk ills in dealing with health care providers. I observed that the experienced mothers utili zed social support more from their families and the community, and had more experience in dealing with health care providers.

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80 The combination of previous childbirth a nd HIV testing had a marked statistical significance (p=.0009) in Model 2 demonstrati ng that the probability of a multigravida who had had an HIV test delivering in a biomedical facility increased (OR=2.98). Number of miscarriages and/ or stillborn: Women who had experienced bad obstetrical outcomes in a previous pregnanc y or pregnancies utili zed maternity health care early and frequently. This has also been documented by Ivanov and Flynn (1999) in their study of bad obstetrical experiences and use of prenatal care. Approximately (N=35) 13% of respondents had had one or more mis carriages. Most of th ese respondents had up to 14-16 visits, compared to the average of seven (OR=0.58). Fear of losing another fetus prompted women to seek prenatal health car e more consistently after a previous bad outcome (p=.03). Women, who had a stillborn an d had not attended prenatal care, blamed themselves for the loss, stating that they unde rstood that a biomedical facility could have provided other options of care. Section D Utilization of Mate rnity Health Care Services Prenatal care utilization: As is often the case in deve loping countries most of the women in this study initiated prenatal care well into their pregna ncy—after the fourth month of gestation (Figure A-4). Despite th is, 68.3% of them (N=181) (Figure A-5) had more than six visits, which is considered adequate in most circumstances, (N=20, 7.5%) had exactly six visits. Still, 21.5% (57) had less than six visits were and 2.6% (N=7) had no visits. Reasons for inadequate or no atte ndance included lack of money to pay for services, not having childcare, or simply not having problems with the pregnancy. To further investigate causes that assist or impede the use of health care services, I

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81 questioned women whom they consulted for advice in making maternity health care decisions. Advisors: Informal advisors play an integral role in health care across the world (McKinlay 1973, Janzen 1978, Feierman 1981). Over half (N=136) of the women reported that they consulted their husband in de ciding on whether to initiate prenatal care, especially if money was needed to pay for th e services or if permission was needed to leave the household. Husbands were also c onsulted if they knew about health care providers or could pr ovide transportation. Other family members were consulted, part icularly when there were complications to the mother or the baby, or if women need ed help with hospital costs. Consultations, however, could have bad outcomes. One wo man reported that she had had prolonged labor, and that the obstetrician had told her and the family that she had a big baby and a narrow pelvis, requiring a cesarean section. Th e husband consulted with his mother and mother-in-law to decide about surgery. They disagreed about it, and while they discussed it, the child was stillborn. Choice of a childbirth delivery center There were five areas itemized in this study of where women chose to deliver their babies (Figure A-6). These are: 1. Home with no assistance 2. Home with a traditiona l birth attendant (TBA) 3. Home with a clinician (nurse /midwife/physician assistant) 4. Level 1 biomedical facility (these levels are explained in detail in chapter 3) 5. Level 2 biomedical facility 6. Level 3 biomedical facility Starting with the top levels which are 2 a nd 3, these hospitals were equipped with urgent care services to care for both moth er and baby. These hospitals had the capacity

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82 among others, to care for an HIV positive mother and prevent MTCT to the baby. Respondents who had attended such f acilities were (N=118) 45%. The level 1 hospital was almost similar to a woman delivering at home with a clinician. Approximately (N=110) 42% of resp ondents used this f acility, which did not have the capability to prevent MTCT or mortality. During the interviews, the clinicians in level 1 centers stated that they referred wo men with complications (HIV positive patients included) to the level 2 or 3 hospitals. However, they sometimes received referred women because they complained of hospital co sts. In the next section, I will explain a woman’s other reasons for choos ing health care facilities. Some respondents, (N=34) 13% asserted preference of a home environment for childbirth, with a traditional birth attendant (TBA). Most neighborhoods had a TBA or were close to a clinic where medical personne l were at times called to assist with a delivery. Reasons for using a facility for prenatal care or childbirth Islamic medical institutions: Women had many reasons fo r choosing a facility. I asked women to choose the five main reasons for why they would go to a particular facility. The most commonly repeated reasons were itemized 1 to 5, (Table A-4) number one being their most important reas on, while five being the least. Since this study was conducted within the Muslim community, I expected the majority would prefer an Islamic run medical institution. I included th is assertion as one of my hypothesis. As stated earlier, only (N=31) 12% stated that they would make religion as a deciding factor, there was no statistical signifi cance in both models. Support of an Islamic establishment or muungano wa Waislamu (Islamic solidarity) was not a reason of using a facility. The three Muslim run hospitals we re built with the intention

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83 of providing access to appropriate health care to those poor Muslims who could not afford the private hospitals, and also as an alternative to govern ment – run hospitals. Women often complained about their dissatisf action with the above institutions which were mainly due to mismanagement and cost of attending them. Respondents who stated using Muslim-run facilities agreed that they used them for tohara or hygienic cleanliness. Another factor named was stara, although this can simply be translated as the upholding of one’s respect and virtue, the context en forces a health care provider the moral and spiritual obligation to protect and honor the individua l in their care. Distance: Distance to a clinic or hospital has been described as a main factor hindering women from accessing health care. In an urban area like Mombasa, where transportation and health care facilities were not far from each other, approximately (N=83) 31% of respondents reported distan ce as a reason for using maternity care. However, distance had a statistical signifi cance (p=.09), with the odds increasing by 74% that a respondent made a choice of a pren atal care facility depending on distance. There are numerous health care facili ties at close proximity around Mombasa. Transportation with matatus (transportation vans) was consta ntly available at a cost of Ksh.10 (equivalent to a United St ates penny). Women did not have to travel far to receive care, however, when I questioned some wome n who had traveled further away from centers closer to home, they stated that they were in search of either better facilities, health care providers or s hopping for affordable care. When choosing a birthing center, there was statistical sign ificance (p=.06), with the odds increasing to almost 78% that a woma n would choose a center due to distance.

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84 Women chose facilities for childbirth closer to their homes, in the event that they went into labor at night, wh ere transportation may not be available. Health care providers: Health care providers infl uence women’s decision of where to go for care. Respondents affirmed th at they moved to different providers in search of good care. The physical and verb al abuse of women during pregnancy and childbirth has been documented by Allen (2002 ), Fon et al. (1998), Okafor and Rizzuto (1994) and Sargent and Rawlins (1991). Interviewees who chos e attendants as reason of choosing a health care facility were (N=115) 43%. There was no statistical si gnificance in model 1, indicating plausible flexibility while a respondent was pregnant. However, in choice of birthing center there was statistical significance (p=.03) with the odds highly increasing at 82% that health care provid ers was a major factor in choosing where a women delivered their babies. Cost: Shopping and paying for affordable maternity health care was a struggle for many women in this study. Although only (N=101) 38% stated that cost was a factor while they searched for affordable prenat al care, with many acknowledging that it was a major factor for choosing a childbirth facility. Most women commented, ikiwa sina pesa sendi clinic (if I don’t have money I don’t go to the clinic). Payment for preventative care was a reason used for not using services, es pecially when other pressing financial needs took precedence in the home. Almost all the women (N=99%) did not ha ve home-births, signifying that although cost was a factor, compromises were made to pay for services or sometimes women were not paying for services. In choosing a birt hing center there was a high probability

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85 (p=.0001) that cost was a major factor, w ith the odds being high that a woman will choose a birthing center depending on affordability. To deal with payments after birth, interv iewees stated that other family members were requested to help with contributions ( mchango ) to help pay for childbirth costs. Women in most hospitals were retained after postpartum discharge until the bill was paid, leaving husbands to raise funds to pay befo re the mother and baby could be released. Nurses reported that at times women sneaked out of the hospitals leaving their babies behind, later to return to claim their babies after paying the hospital bill. Attendants at the home-birthing centers complained that they had to force women to pay a deposit before childbirth with the fear that, that would be the only payment to be received after the woman and the baby left. The balance with so me women would be given in installments, however with some there would be none. Health care services: The choice of health care serv ices went hand in hand with health care providers, With the majority of the respondents (N=186) 70 % agreeing that they chose a facility according to services provided. These services included the interaction with providers, and the efficiency of the establishment in terms of delivery of care. Interviewees stated that waiting pe riod to be seen by a provider was important, availability of medication, f unctioning equipment and labor atory. Although majority of the respondents stated these services were very important about (N=147) 55% of them delivered in childbirth centers that could not provide emerge ncy life saving services for them or their babies. Millions of women gl obally have babies without problems, however when there are obstetrical complications th ey are immediate and require swift action. Obstetrical emergencies that could cause ma ternal morbidity are hemorrhage, obstructed

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86 labor, sepsis, and eclampsia. Since this study also assessed women’s measures to prevent mother-to-child HIV transmission, any of the 55% of respondents who might have been HIV positive would not be in facilities that could prevent MTCT. In both models there was no st atistical significance in choi ce of health care services as a reason of choosing a health care facility. Health problems: I inquired if women chose a h ealth care facility depending on health problems particularly in pregnancy. The major health problems mentioned during pregnancy, although some are not pregnancy rela ted were anemia (due to diet and/or malaria), malaria, typhoid, pregnancy induced hypertension or pre eclampsia, and vaginal discharge (due to reproductive or sexual tr ansmitted infections). Respondents who chose facilities due to any of the above health problems were (N=18) 7%, plus there was no statistical significance in both models in wome n’s responses to how they managed any of the above.

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87 CHAPTER 6 ETHNOGRAPHY OF PREGNANCY AND CHILDBIRTH Introduction In this chapter I provide women’s narrative s of their recent experiences and explore what they see as normal and what they s ee as illnesses in pr egnancy. In addition, I include societal and cultural factors that possibly delay women from starting prenatal care. These narratives reveal th ings about the use of maternity health care that are not captured by the questionnaire data. From t hose data, Islamic institutions were not significant in women’s preference of a childbi rth facility. Yet, more than half (N=144, 54.3%) of the women delivered in centers wh ere the caregivers we re mostly Muslim women. However, when variables that had statistical significance, such as cost, health care providers and distance of the centers are considered, it is not surprising that women deliver in these facilities, because they are cheaper, and closer to the neighborhoods. Menstruation and Puberty Rites – Lesso ns On How to Safeguard Fertility Pregnancy is a blessing ( baraka ) with prayers given constantly for the wellbeing of the mother and baby. Good and bad outcomes of the pregnancy are God’s will or one’s destiny (majaaliwa ya Mwenyezi Mungu). As explained by Sered (1994: 188) “conception, pregnancy, labor and delivery and the postpartum period may be fraught with uncertainty, fear, dange r, deep relief and a sense of wonder”. Women left the outcome of their pregnancy to fate and in “God’s hands” (what will be, will be). This fatalistic attitude was repeated and rep eated by almost all the women. Women are cautioned to avoid early claims of a pregnanc y, which could bring bad luck or harm from

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88 the evil eye ( hasad ) of others and cause a miscarriag e (see Chapter 3). In addition, older women who have seen many pregnancies no t reaching term, caution younger women not to rejoice during pregnancy until a normal healthy baby is born. Secrecy and pregnancy are societal concepts taught to protect the mother and fetus, from possible mishaps and from those who are barren who might cast an evil eye out of jealousy on the pregnant woman. Thus, other than the spouse and the wo men in the very immediate family, the beginning of a pregnancy is not announced. On e woman stated “I did not tell anyone that I was expecting. They confronted and aske d me when I started showing”. Secondly, announcing a pregnancy is a public statement of sexual intercourse, which is against the codes of public modesty. These concepts are important in understanding why women start prenatal care late—that is, until they are phy sically showing, after the fifth month— or not at all. The beginning of menstruation or puberty ( baleghe or kuvunja ungo ) is tied to the start of fertility. Being fertile means fu lfilling the role of being a woman. A young woman is taught not to discuss the beginni ng of menstruation with others for selfprotection. This code of secrecy about matters relating to fertility continues to pregnancy, and childbirth. The code is so important that formal lessons, with a special teacher ( somo or kungwi ) are purchased for the initiate ( mwari). Codes of public modesty for women are taught from childhood in all societies. An old initiation ritual to womanhood, called unyago was studied by Strobel (197 9). Caplan (1976) describes a comparable practice among the Swahili in Tanzania. Others who have also examined reproductive or female initiation rites similar to unyago are Brown (1963), Kitahara (1984) and Schlegel and

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89 Barry (1979). Unyago was a big societal celebration performed with seven days of drumming ( ngoma) It started at the beginning of a girls’ first menstruation to the last day when she is publicly bathed ( kuoshwa ) before “coming out” and being presented to society as ready for marriage. Remnants of this ritual ar e still found in Mombasa. An older female relative or neighbor provides instruction, for a small f ee, on hygiene during menstruation and how to ritually bathe afterwards. The somo teaches the mwari how to use the menstrual cloth and the instructions are given for the first three months of menstruation. Today, the mwari is taught how to use sanitary pads and, more impor tantly, how to discrete ly dispose of them. Lessons include on how to keep track of th e menstrual cycle and how to purify the body after the menstrual period ( tohara) The somo’s lessons emphasize secrecy in hiding the menstrual cloth or pad (including from a hus band), as well as inst ructions on a woman’s duties in the house and community and on how to be a good wife and mother. The somo is responsible for her mwari’s behavior both in the commun ity and in her marital home. The teaching between somo and mwari is kept a secret, with the mwari not sharing the teachings, even with age mates unless they have the same somo The somo plays a major role when the mwari gets married; she is called the “other” mother. She may be included in dowry negotiations and is th e first called to settle marital disputes when they arise. During childbirth and the postpartum period the somo would be called to assist the new mother and baby. The somo would expect her mwari to be brave and not embarrass her during labor and childbirth. Screaming or cr ying out in pain would not be acceptable behavior. Furthermore, complaining about the hardship of childbirth is not encouraged.

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90 The new mother has to be grateful and thank God ( mtu hushukuru Mungu ) for the safe passage to motherhood. Cultural practices in preparation for womanhood are ubiquitous, but the demands of both Islamic and secular education ma ke keeping up with these cultural norms difficult. Although all Muslims practice tohara the puberty rite of somo/mwari is practiced mostly by the Mijikenda and some Waswahili. The Arabs and some Waswahili, on the other hand, practice kutawisha which is the seclusion of the girl at puberty and the reinforcement of modesty ( heshima ). Modesty traits include bashfulness, humility, diffidence and shyness. The initiate ( mwanamwali ) is enjoined to practice purity, fidelity and chastity, which is tested on he r wedding day (Antoun 1968). At puberty, the mwanamwali cannot be seen or heard in public. When out in public she has to be escorted and covered, wearing the outer black garmen t that conceals her body from head to toes ( bui bui or thaub ). Secular and religious schooling out of the home may be discontinued. I was informed that the teaching of codes of modesty for an Ar ab girl begins earlier with genital cutting, a variant form of clitoridectom y, performed as a purification rite. Female circumcision is a code of modesty increas ing a girl’s possibility of marriage (Yount 2002). Morsy (1993:84) also explains a sim ilar practice in Egypt as purification ( tahara) performed at twelve years of age. The age of female genital cutti ng in Mombasa varied between ages two to twelve years, or just before puberty with similar intentions of safeguarding women’s honor or assuring the girls’ chastity before marriage. The sides of the clitoris are excised, without th e complete removal of it. This is classified as a Type 1 form of female circumcision (WHO 1995). Fema le genital cutting in many parts of the Muslim world is considered sunna (which denotes the sayings and doings of the prophet

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91 Muhammad as described in the stories after his death) though it pred ates Islam and it has no Quranic reference (see Gruenbaum 1996, Johnsdotter, 2003, Morsy, 1993, Yount 2002). The strength of the concep t of modesty for women cannot be overestimated among Muslim women, and particularly among Arab Muslim women. Allen (2002:165) reports that Arab women in Tanzania also avoided early prenatal care due to embarrassment about their pregnancies. In addition, Wall ( 1998: 350) in his study of the Hausa-Fulani explains that the social pressure for wome n to “remain modest” might prevent them from seeking health care or aski ng questions about childbirth. Similarly, Goodburn et al. (1995) in their research of be liefs and childbirth practices in rural Bangladesh claim that Muslim women practice purdah (social isolation) for modesty and to conceal pregnancy because of shame attached to being pregnant. Infertility Infertility is the failure by a couple to conceive af ter a year of unprotected intercourse. In this study I observed ma ny women undergoing s econdary infertility, defined by Odile (1983:140) as “the inability to have a child subsequent to an earlier birth after a reasonably long period”. Failure to conceive often generates feelings of frustration, inadequacy, emotional stress, a nger, guilt and resentment. Katz and Katz (1987: 395) explain that “infert ility is a devastating problem for women in cultures where childlessness carries a strong so cial stigma and where children offer assurance of both personal and old age insurance”. Causes and probl ems of fertility and in fertility in Africa have been studied extensively (Agadjania n (2001), Hopkins and Revson (1979), Kokole (1994), and Odile (1983)). Women w ho cannot bear children are called tasa meaning, barren, pitied by relatives and at times ridicule d by in-laws. In contrast, the term for a

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92 man who is sterile is “ hanithi, ” which also means homosexual. After the first year of marriage, the social pressure begins if a woma n is still not pregnant with questions, such as “not yet?” or “still not pregnant?” ( je vipi bado au mbona hujabeba? ). A woman who cannot conceive is encouraged by the family to choose a second wife for her husband so that the new wife can have children. Children bo rn in such an arrangement are shared by the first wife when there is a cordial or respectful first/second wife relationship. During my interviews, about one out of four women ha d a story of frustrati on due to infertility. Women provided details about their quest to get pregnant. The tradit ional birth attendants and the healers also explained that they ha d long term patients who had not conceived. Since I interviewed women who had given birth, the respondents’ narrat ives are the result of success stories after infertil ity treatments. I interviewed Hamida, aged 34, after she had her third baby. She has two daughters, one 15 years of age, an 11 year old and now the new baby. She has suffered from infertility a nd as she explains, she was not treated by just one healer: My last daughter is now 11 years old. I ha ve been unable to get pregnant until now. I went to Dr. Patel (private physician) on and off for treatment when I had money, it has been very expensive. She gave me pills to take and told me the medicine will regulate my periods (hormones). I have al so gone to Mama Msena who said that my problem is mshipa2 or blocked fallopian tubes. She massaged by abdomen at every visit, gave me oral liquid herbal medicine and vaginal suppositories. This treatment was not very cheap either, but bett er than at Dr. Patel’s. Last year as a last resort, my husband suggested an Islami c healer who read the Quranic verses to remove any hassad or evil spirits that might be stopping me from becoming pregnant (Informant 009). Infertility is treated through biomedical, spiritual and traditional medicine; none of which are mutually exclusive. Biomedical tr eatments for infertility are very expensive. 2 Mshipa is a diagnosis given to a myriad of complaints. The literal Swahili meaning of the word mshipa is a blood vessel, or a nerve. Therefore, pain in the legs, stomach or any other part of the body could be a result of mshipa I clarified with Mama Msena that the mshipa she meant was of th e reproductive tract.

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93 Very few women are able to afford the pr ocedures, which sometimes involves surgery. As a woman gets desperate, different remedi es are sought, as the above case describes. For Hamida, it took a combination of treatment s for her to become pregnant. She stated that God had not granted it to happen ( Mwenyezi Mungu alikuwa hajajaalia ) and this was the reason given by all women who had had pr oblems with infertility. However, while women waited for God to grant them the baraka they also were pr oactive in seeking treatments to treat their infertility problem. While I was interviewing another res pondent, a woman who had been patiently listening argued that biomedicine could not cure infertility problems that needed traditional healing methods such as spirit possession. She explained that she had been pregnant for a year, and had gone for an ultr asound, only to be informed that a fetus was not seen. She was adamant that she was pregna nt and she assured me that when I return to Mombasa after a year I will be shown the baby. This condition is biomedically known as pseudocyesis or pseudopregnancy (Small 1986). It is believed in medical science as psychogenic in origin. However at times, fo llowing a cure the woman can get pregnant and have a healthy baby. In a national su rvey study, Coreil et al. (1996:424) found pseudocyesis, or “arrested pregnancy syndrome,” common in Haiti. Murray (1974) reports that women in Haiti (or their partne rs) who self-diagnosed as having a prolonged pregnancy were in a state of “perdition” Murray hypothesized that the condition is a culturally sanctioned face-saving mechanism for infertile women in a setting that places enormous pressure on women to bear chil dren. Women in Mombasa who stated they were in such a state underwent diagnosis by a healer, who confirme d the pregnancy. Two such women, whom I interviewed, had previously had healthy infants. Presently, they had

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94 irregular periods, their abdomens were diste nded and they even claimed that they felt fetal movement. This form of “hysterical pregnancy,” (Murray 1974) involves external symptoms with the absence of a fetus. Mama Msena and other healers stated they had treated many such pregnancies with success. Similarly, In Haiti, the “goal of treatment for a woman in perdition is to reinstate the gr owth of a child which has been trapped in a woman’s womb” (Murray 1974:67). Healers treat infertility th rough regulation of women’s menstrual cycle, and I was informed by some of them that one of the major causes of the problem is a cold womb ( uzao umepata baridi ) or a closed womb ( kizazi kimejifunga ). One of the remedies for this was the application of a special remedy on the man’s penis before sexual intercourse to warm up or open the uterus. Infertility was treated by male and female healers for both men and women depending on the cause of th e problem. Healers that were treating the women stated that they simultaneously tr eated the partner. Possession by disgruntled spirits ( ruhani ) that might affect either partner was also given as a reason for infertility. Rukia, a 28 year old who had just delivered her third baby explains: I delivered my first child, six years ago but she had already died in my uterus. The second one was three years ago and he di ed after one week after birth due to diarrhea and vomiting. I was not taking anyt hing to stop me from getting pregnant, but I was taking too long to conceive. I initi ally went to the hospital to find out why I could not have a baby after a year. They took me to the theatre (operating room) and cleaned my uterus (dilatation and curettage) ( wakanisafisha uzao ). I still did not conceive, after five years of seeing bot h Western and traditional healers, I went to see Mzee Ali who is both a traditional a nd Islamic healer. He informed me that I was possessed with a male spirit ( ruhani mume ) who was unhappy because he was not invited or informed of my marriage and my wish to conceive. I was given herbal medication and ordered to wear a ring with a sapphire stone and an emblem of a mosque. I had to provide two chickens, a black and white one, plus a goat. I became pregnant six months later and this is the result (showing off the son) (Informant 067).

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95 Pregnancy Loss Spontaneous abortion or miscarriage is th e loss of products of conception before the twentieth week of pregnancy. The body reje cts a fetus that is not developing normally in about 25-60% of cases. Kuharibu mimba in Kiswahili, or miscarriage, translates as something in the uterus being spoiled or ru ined. Women explain miscarriage or the death of a baby as also God’s will ( Mwenyezi Mungu amejaalia ). The first miscarriage may be overlooked. However subsequent lo sses are considered to be the act of malevolent spirits, or angry animate forces or hasada from oneself or other people. To prevent miscarriage or protect the pregnancy, a sp ecial herbal or spiritual reme dy is given to the expectant mother. This preventative treatment is called nyongo or nyongoo performed mostly by the Mijikenda. Nyongoo treatment is shared by the other groups when a woman is desperate to protect a pregna ncy and preserve a wanted ba by. Women who are advised to start nyongoo preventative treatment and do not are suspected of not wanting the pregnancy and sometimes ostracized. The treatm ent is given either before conception or after. However, according to a healer, the appropriate time is between the sixth and seventh month of gestation. All Miji kenda women are advised to receive nyongoo treatment. Mama Mishi, a healer, argued th at many secular and re ligiously educated women are not receiving nyongoo treatment. She argues that th is is the reason why there are many complications related with pregnancies. When some of the women do not go to healers for the treatment, a family member, mo stly the mother or mother-in-law, will get the treatment for them. Wo men who have had problems with infertility, difficult pregnancies or stillbirth s are more likely to use nyongoo treatment and take precautions for a healthy obstetrical outcome.

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96 Women who start premature la bor are treated at home by TBAs. Bi Zuena (a TBA) explained that there are herbal treatments to strengthen and help the baby mature, plus close the cervix until the appr opriate time for childbirth. She advised that her treatment to stop a miscarriage or premature labor was boiling a type of seaweed ( mnafisi ) and giving the liquid to the mother to drink. Perceptions of pregnancy The Kiswahili term for pregnancy is mjamzito which means one carrying a heavy load. This also insinuates th at the one carrying the heavy load needs help and sympathy. It is not unusual to hear older women reprimanding husbands or other family members for not helping a pregnant woman, particularly in the last trimeste r “Can’t you see that she is carrying a heavy load?” “ Humuoni mwenzako mjamzito ?” Attention for pregnant women does not only come from the husba nd, but also from the extended family. Pregnancy does not stop women from conti nuing with their daily chores. However assistance is given when the work is strenuous or the woman is tired. On the other hand, women who use pregnancy as an excuse not to perform their regular chores are also quickly reminded that pregnancy is not an illness ( mimba si ugonja). The concept of carrying a heavy load is the reason women pursue massage therapy for body aches and pains. Approximately half of the respondents in th is study stated that they had been to a masseuse at one time or another during the pregna ncy to relieve lower back pain, pelvic and general body discom fort. These discomforts are normal in pregnancy as musculoskeletal changes occur with the growing fetus. Massage therapy during pregnancy is beneficial since it increases blood circul ation and relaxes muscles. However abdominal and sacral massage should be avoided in the third trimester (Tiran and Mack 2000). Women are hired as masse use therapists and paid about Ksh. 20-100

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97 (less than a dollar) depending on their expertise. Reference is through word of mouth on who is a good masseuse. Shopping for a good masse use is similar to the search for a good health care provider. Women report good masseus es got rid of their aches and pains and they felt better. On the other hand, there were stories of bad experiences with inexperienced masseuses. One woman comp lained, “My abdomen was massaged so roughly that my baby’s position was changed, I ne ver went back to her, but I had to find another therapist to fix the position of the baby”. Another informant stated that her masseuse was also rough and her whole body ached for a week. These concerns were voiced by many women that the masseuses were either too rough or aggressive creating more body discomfort than good, plus possibly changing baby’s position. The external manipulation of a baby’s position in utero is performed as well in hospitals. This is when a baby’s buttocks present instead of the head in the birth canal. Women furthermore explained that they went for massage whenever they felt that the baby was sitting too low, or in th e wrong position. Women were very concerned about having the baby in the right positi on. However women did not go to health departments or hospitals for such complaints Traditional birth atte ndants also practice massage therapy. During the massages, TBAs le isurely communicate with their clients, to know more about the pregnancy, family life a nd issues that might be affecting them. They might also provide herbal oral medica tion for pregnancy related discomfort. A TBA explained that proper massage does not harm the mother or the ba by, but provides relief; nevertheless she looks for further problems and refers the woman to the hospitals when necessary. She added that asking women to go to the hospital before massaging them would not be providing the proper care, because it would upset the woman or push her to

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98 seek another therapist. In many instances, th ere is social pressure for women to avoid seeking biomedical care without first trying home or traditio nal therapy. Over the counter medication to relieve discomfort, such as Pa racetamol (equivalent to Tylenol) was used. Some women explained that ma ssage therapy was not their first choice. In an interview Khadija a 39 year old mother of two stated: I was not feeling well, I was told by my grandmother to go to Mama Dogo (a healer) because of excessive vomiting and not feeling well. I was now in my seventh month and I was loosi ng a lot of weight. Instead I went to see Dr. Mala (a private doctor) who admitted me in the hos pital; they gave me intravenous fluids and other medicines. After I left the hosp ital, I now complained to my grandmother that the baby was very low ( mtoto ameshuka ). She sent for Mama Dogo a masseuse to massage me and lift the baby ( amuenue mtoto ). Mama Dogo made me some soups and porridge which she added herb s to give me strength (Informant 055). Successful uncomplicated pregnancies ar e celebrated with an offering called tangalizi. This is done at the beginn ing of the ninth month. A m eal that contains seven different grains is prepared and given out as an offering. Th e meal is divided into three portions; one given to people af ter prayers at a mosque, a por tion is given to neighbors, and some to the poor. The seven grains chos en are; whole wheat, black-eyed peas, split peas, kidney beans, lentils, adzuki beans, and millet. These are boiled separately until cooked, and later combined, and served with grated coconut. The expectant mother does not eat the tangalizi since it is an offering. Underlying the childbirth rituals are traditional and religious acts that emphasi ze the dangers of birth and th e need for divine protection (Sered 1994). Tangalizi is not an Islamic religious pr actice; however there are certain prayers ( tawasuli ) that are performed together with the offering to remove hasad and to seek divine intervention. The persistence of beliefs and pr actices which deviate not only from “normative Islam”, but also from Isla mic orthodoxy as it is locally defined and

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99 understood is common in Muslim societies, su ch as Mombasa, and women are the focus of the maintenance of such beli efs and practices (Ladislov 1988). Prohibitions in pregnancy Taboos on behavior during pregnancy appear to be attempts to curtail parental access to things or situations that may pr ove harmful to the child (Montgomery 1974: 160). Pregnant women are reminded that certai n actions and/or foods might affect their pregnancies and ultimately the baby. Sered (1994:204) contends th at for “pregnant and birthing women who are part of cultures in wh ich individuals are not seen as controlling their own destinies, indirect tactics like rituals are appealing methods for dealing with fear, conflict, and the need for attention”. Women are not allowed to tease or laugh at an individual with a deformity otherwise the baby will be delivered deformed. Similarly, they cannot hate a person ot herwise the baby will be born with that person’s physical characteristics. Being outdoors during dusk might expose the woman and her baby to evil spirits. Illicit sexual practice by either partner would produce a sickly baby ( mwana wa kuchirwa ). Preservation of the pregnancy and the wellbeing of the developing fetus becomes a family affair. Food restrictions ( miko ) are enforced for those who can afford food choices. So-called hot foods, such as cassa va, raw mangoes, hot chilly, honey, beef, lemon and limes, plus certain spices, such as black pepper and ginger, are forbidden for the pregnant woman. Hot foods taken in the first trimester are be lieved to act as an abortifacient. Manderson ( 1981:511) argues that in most societies, food taboos in pregnancy are “in the interest not of the moth er but of the health of the unborn child and its appearance at birth”.

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100 Women, who have problems before the ni nth month of pregnancy, go to healers such as Bi Zuena and women of Baluchi ethnicity for treatment. Mama Msena on the other hand, explained two types of treatments to prevent stillbirth or babies that do not grow well in the womb. Women in my samp le who had delivered a stillborn went for nyongoo treatment or were treated for mwajuu (high blood pressure) as I will later explain. Illnesses in Pregnancy I asked women about what they perceived as illnesses that can harm them or their babies. Approximately 36% (N=93) comp lained about having suffered and had documented evidence of treatment for one or more of the following: pre-eclampsia or mwajuu anemia ( upungufu was damu ), fever ( homa ), and reproductive tract infections ( shango ). Pre-eclampsia: Pre-eclampsia or pregnancy induced hypertension is the development of high blood pressure with evid ence of protein in the urine (albuminuria) or edema (swelling of the hands or face) be tween the twentieth week of pregnancy and the end of the first week of postpartum. Untreated pre-eclampsia can lead to eclampsia which is a state of coma and/or convulsi ve seizures. Causes of pre-eclampsia and eclampsia are unknown, although 5% of pregnant women develop it, mostly in first time pregnancies or in women with a history of hypertension or vascular disease. Women suffering from pre-eclampsia die from eclamps ia, renal complications and coagulopathies (blood clotting disorders) among other severe complications. Treatment is aimed at preserving the life and health of the mother and consequently the fetus survives. Hospital management of severe pre-eclampsia is impe rative to prevent eclampsia (Merck Manual 1992). In this study 5.7% (N=15) reported having been diagnosed with this illness, and

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101 the majority of them (N=11) also received tr aditional herbal thera py for it. Symptoms of pre-eclampsia correlate with a local condition called mwajuu. Mwajuu, as explained by the healers, is char acterized by symptoms of swollen feet, face and hands ( kufura migoo, uso na mikono ). The pregnant woma n complains of not feeling well ( asikia vibaya ) and has decreased urinary out put in the advances stages. Traditional herbal remedy is provided by specialists and not all healers treat mwajuu although they may provide the diagnosis. Bi Ri ziki at the Majengo market was the healer consistently mentioned as having the treatment for mwajuu I was informed that the treatment was not complicated. However, finding the right herbs, consistency and course of therapy to be followed needed a healer with experience and knowledge. Bi Riziki explained that the main ingredient in the he rbal treatment was to increase diuresis or removal of body fluids in order to decr ease the swelling and lower the woman’s blood pressure ( presha ). I further inquired when she thought the woman should go to the hospital due to advanced illness. Bi Riziki sa id that the best time is when the patient could no longer walk to see her for furthe r consultation. She does not do home visits. Many of the interviewed had a lot of faith in mwajuu herbal therapy. A few even stated that hospital treatment was not effective, that this illness requires traditional healing “ugonjwa huu wataka utabibu was kikwetu” This belief at times resulted in complications as the following respondent, Amina explains: I was not feeling too well at 11a.m., my mo ther escorted me to Mwembe Tayari health department for a check up. After they checked me, the nurse told me that my blood pressure was very high and my urine test was not normal. I was referred to Coast General Hospital (CGH). My mother advised me to go to Mama Mishi (a TBA) and a family friend to see if I had mwajuu, plus get treatment from Bi Riziki. Mama Mishi agreed that I needed mwajuu treatment, but by 4p.m. I was feeling really bad. They got me a taxi and took me to CGH, there I started having seizures by 6p.m. and became unconscious. They tell me that they took me to the operating

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102 room and removed the baby (cesarean sect ion), but the baby died. She was a baby girl. I stayed in intensive care and re gained consciousness three days later (Informant 084). Amina is a 28 year old woman who was expecting her second baby. She had had 10 prenatal care visits and e xplained that the main reason for not going straight to the hospital as advised was her moth er’s lack of trust of the bi omedical facility in treating mwajuu She also complained that she was am bivalent about going to CGH due to the hospital’s reputation of having r ude health care providers and poor care. I further inquired about her experience during he r hospital stay. Amina was re lieved that her perceptions did not match the care she received. The hosp ital staff was not rude to her, although she complained of the hospital cost. The decisi on not to follow the re ferral recommendation had an unfortunate and grave consequence. Ba rnes-Josiah et al. (1998 : 981) explain that high rates of maternal mortality in third worl d countries are due to delay in “deciding to seek appropriate medical help for an obs tetric emergency, reaching an appropriate obstetrical facility and receiving adequate care when a facility is reached”. Amina refers to the loss of her baby as God’s will ( Mwenyezi Mungu hakunijaalia rizki ). Amina was among four women I interviewed who had experienced extremely bad obstetrical complications. Some cases of preeclampsia did not have similar bad outcomes as explained by Samia, also aged 28 years ol d after her second childbirth: I was diagnosed with pre-eclampsia afte r my first pregnancy. I did not think I would have the same problem again. I we nt to Spaki maternity home, where the nurse referred me to a private obstetric ian – although expensive, I agreed. The doctor advised me to stay at home, not to do any housework, but to rest in bed and gave me high blood pressure medicine, wh ich I took. My neighbor visited me and gave me mahlab (an Arabic home remedy for high blood pressure); I used this three times a day. Mama Nuru (a healer and TBA) was brought to massage me for backache, and when she saw my swollen feet she suggested that I should be given mwajuu medication. Mama Nuru went to Bi Riziki and brought the treatment. I

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103 took all the medicines and in the last month of my pregnancy I moved to my mother’s house to prepare for delive ry. I delivered a healthy baby at the neighborhood maternity home, it has a na me but I cannot remember it. The hospitals were too far from my mother’s house (Informant 064). Samia’s story was consistent with many othe rs that I heard in the use of different healing remedies to treat one ailment. Since she had a history of preeclampsia, a biomedical recommendation would have been for her to deliver in a hospital under medical supervision to prevent further comp lications. However, she made choices that were comfortable for her in her environment and in her condition. Anemia: Women complained of feeling weak due to “decreased blood” ( upungufu wa damu) I interviewed women who had been di agnosed with anemia and were being treated. Iron deficiency anemia is responsib le for 95% of anemia in pregnancy. Normal iron values decrease during pregnancy. Iron supplements are recommended in oral iron preparations such as ferrous sulfate tablet s. Pregnant women are advised to increase foods rich in iron in their daily diets. Duri ng the interviews, approximately 6% (N=17) of women were diagnosed with severe anemia. Quite a number of respondents stated that they had symptoms of anemia, but had not b een tested. Lack of diagnosis and records prevents our knowing the effects of anemia in pregnancy in third world countries. Women with severe anemia in pregnancy have increased incidence of infant mortality (Marchant et al. 2004). Symp toms of anemia consist of weakness, ease of fatigue, dizziness, headaches, and ringing in the ears. A woman’s health status particularly with anemia plays a major role in pregnancy and in childbirth outcome. One causative factor of anemia in women is nutrition deprivation; however malaria is also a major cause in Mombasa. TBA’s and healers also provide nutritional herbal supplements to assist increasing women’s iron levels As explained by Saida:

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104 I was tired all the time, even after just taking a shower, this was in my fifth month of pregnancy. I went to Sayidda Fatima hosp ital where I was getting prenatal care. I was given iron pills, they were making me nauseous ( lakini zilikuwa zikinichafua roho ), so I only took them some times. I dr ank milkshakes of milk and dates, or milk and egg yolks; I was told this increas es blood and would increase my strength ( maziwa na mayai au tende yaongeza damu na nguvu ). But I developed breathlessness and at the hospital they said I would need a blood transfusion before I had the baby. I became scared and I went to see Bi Zuena who gave me sikijabili which I had to drink a quar ter of a teacup three times a day. When I had the baby, I was not very strong, but they did not have to give me any blood. I still feel weak when I do heavy work but I still continue with sikijabili (Informant 112). Saida had suffered from malaria and t yphoid with this pregnancy, requiring hospital admission. When I met her she was stil l pale and struggling with daily household chores, which she explained she had ma naged well before the illnesses and the pregnancy. She was among many informants who stated that they avoided blood transfusion when possible, trying other oral medications from hospitals or home made remedies. Bi Zuena was the main healer women went to for herbal iron supplement. She prescribes a syrup she calls, sikijabili (a combination of raisins, tamarind, brown sugar, fennel seeds and cinnamon powder). Bi Zuen a does not stop women from continuing with the iron pills given at the hospital. Women, who prefer sikijabili complained that the iron pills gave them constipation and naus ea. I inquired from the clinicians if there was a substitute for the iron pills. A multi-v itamin, Fefol was substituted for a slightly higher price. A bottle of sikijabili was more expensive than Fefol, or iron pills, although more accepted by some respondents due to the lack of possible side effects. Fever: Fever is defined quantitatively as a ri se in body temperature above the daily normal variation of greater than 37.8 degrees Celsius (100 degrees Fa hrenheit). Fever can be caused by infectious or non-infec tious disorders. On the other hand, homa is a rise of body temperature that can be th e result of fever but may also be the result of a common

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105 cold. Homa may involve feeling very hot or ve ry cold, especially with shivering, headaches or general malaise. Homa can be caused from inside one’s body or from outside, including “bad air” ( upepo mbaya ). Most respondents complained of having had homa at one time or another in their pregna ncy. The two main illnesses reported as the cause of fever were typhoid and malaria. Twenty-two women (8.3%) reported having been diagnosed and treated for typhoid fever and/or malaria. I report these numbers together because most of the respondents had suffered from both. Typhoid fever is a system ic infectious diseas e caused by Salmonella typhi, and is characterized by fever, prostration, diarrhea, abdominal pains, and a rose colored rash (Dildy et al. 1990: 274, Sadan et al. 1986:807). The t yphoid bacillus is endemic in areas where sanitary measures ar e inadequate and is spread through a fecaloral cycle through inadequate hand washing, contaminated food, flies and water. As explained in the previous chapter, women in Mombasa spend a lot of time and energy in the collection and preservation of clean wa ter. Pregnant women who cannot handle the strenuous task of collecting and boiling wa ter at times succumb to typhoid fever. Treatment for typhoid is with antibiotics. Pregnant women who de velop typhoid fever are at high risk for obstetric comp lications such as spontaneous abortion or premature labor (Zenilman 1997: 847). Untreated typhoid results in maternal morbidity and mortality. Since typhoid outbreaks are common in Momb asa, women were aware of the symptoms. Samira, an informant who had been hos pitalized for typhoid fever, explains: I started having headaches and diarrhea sinc e the beginning of my fourth month of pregnancy. This continued on and off and I kept going to the hospital (CGH) for treatment. They took my blood and stool and tested them; the doctor said I had typhoid. At night I had fever and chills. Si nce the problem did not stop I kept going back to the hospital and they gave me antibiotics. I would stop having the problem and it would start again. When I was seven and half months I started leaking water

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106 that was around the baby(amniotic fluid) ( chupa ya maji kwenye uzao ilivunjika ). The doctor told me I should stay in the hos pital otherwise I would loose the baby or the baby would come out early. I knew G od knew best if this baby was going to survive or not ( najuwa Mwenyezi Mungu ndie mwen ye kujua ikiwa huyu mtoto ataishi ) I was already tired of being in and out of the hospital, so I went home and waited for the baby to come. I had already fi nished the medicine that they wanted me to take; they said they wanted me to stay in the hospital to protect the baby. I had this baby three weeks early, and she is healthy. I still have problems with typhoid and I have to keep going back fo r testing and treatment (Informant 258). This was Samira’s fifth child; she had a hi story of one previous miscarriage at two months. Despite having typhoid, she refused to be admitted because of not having anyone to take of her other children. She risked losing this pregnancy or having a premature baby because of having to care for the othe rs. This was a dilemma faced by many other women I interviewed who had either suffered from typhoid or malaria. Relapses occurred in many women, increasing their health deteri oration and the cost of re-diagnosis and treatment. Women’s poor health leads to a decreased immune system, thus increasing their susceptibility to othe r illnesses such as malaria (Brabin 1983) or anemia. Malaria: Malaria is one of the most common infectious diseases in Mombasa. Malaria causes anemia in pregnancy and is the primary cause of maternal and infant morbidity and mortality in this area. Most Mombasans develop some immunity to the disease due to repeated infections. Many studies have assessed the effects of malaria in pregnancy (see Nyamongo 1998). Nosten et al (2004) summarize th e pathophysiology of malaria in sub-Saharan Africa. This study has concentrated on one of the main causative organisms of malaria, Plasm odium falciparum, the most common source of malaria in Mombasa. Pregnant women who suffer from ma laria risk abortion, stillbirth, premature delivery and low-birth weight babies (Guyatt et al., 2004, Dic ko et al. 2003). In addition, Van Geertruyden (2004) has reported on peri natal mortality caused by malaria in pregnancy. Prevention of malari a in pregnancy through the pr omotion and distribution of

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107 insecticide treated bed nets for women attendi ng prenatal care was started in Kenya by UNICEF (Guyatt et al. 2004). Pr egnant women who attend pr enatal care are given two doses of oral suphadoxine-pyrimethamine once during the second and third trimesters to prevent malaria (Holtz et al. 2004). Malaria in pregnancy increases the inciden ce of anemia (Matteel i et al. 1994), and possibly preeclampsia in first time pregna ncies (Sartelet et al 1996). Some women who had attended prenatal care received malari a prophylaxis, and had taken the medication. They were aware of the dangers of not taki ng the medication. Wome n and healers stated that Western treatment for malaria was prefer able, especially since the herbal treatment could not be used in pregnancy. The herbal treatment used for treating malaria and other types of fever is the leaves and pa rts of the bark of a tree called muarubaini Healers added that drinking the boiled leaves of the muarubaini could cause an abortion. Steaming and bathing with the water was recommended in pregnancy since it reduced fever. Women also buy over-the-counter anti -malaria drugs such as, Fansidar and chloroquin and self-treat when ha ving fever or suspecting malaria. Reproductive Tract Infection ( Shango ): Pregnancy predisposes women to increased vaginal discharge or leucorrhea. For some women this begins from the first month of the pregnancy. Leucorrhea does not require treatment; women are advised about good personal hygiene, and wearing co tton underwear. During the interviews, a lot of women brought up issues of vaginal disc harge, so I probed for more about the problem. I knew that women ordinarily used wa ter to cleanse after using the toilet; but did not use toilet paper. Some women were also aware of signs of vaginal infections, such as burning, itching, change of vaginal odor or fever. These symptoms were not

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108 described by the majority of the respondent s. I checked with midwives and physicians who stated that they treated women with sy mptoms of fungal, bacterial vaginosis and sexually transmitted infections. The majority however went to traditional healers. Healers that I interviewed claimed that va ginal discharge in pregnancy is shango and its recurrence cannot be treated bi omedically. They indicated that even after receiving biomedical treatment, to be healed women still needed shango treatment. Shango is a general term for all vaginal infections dur ing pregnancy, however differential diagnosis and treatment changes depending on the symp toms. The healers explained the different types of symptoms related to sexual and non-sexual infections. For example, Mama Msena described the treatment for syphilis ( kisonono ) differently from the shango remedy. Women who had used shango treatment also related the problem with other pregnancy discomforts, as Mwanaisha explains: I was in my fifth month of pregnancy, I had gone for a docto r’s hospital visit, because my baby was very low ( mtoto yuko chini ), and I was uncomfortable because of the discharge. The doctor gave me medicine to put down there (vaginal suppository). Since the baby was already low, I went to see Mama Mishi (a TBA and healer) who told me I should use the hos pital medicine, that it will not hurt the baby. She showed me how to use the medicine. She said I had mwamimba a condition that can make me loose the baby if not treated. She gave me shango treatment to help the hospital medicine and massaged me to lift the baby, since I could hardly walk ( hata kutembea nilikuwa siwezi ) (Informant 016). Mwanaisha is a 20 year old, who had de livered her first baby. She was among many respondents who used both biom edical and herbal treatment for shango However, some respondents who had experienced shango from previous pregnancies only went to traditional healers. Zubeda, a 26 year old mother of three stated: I have suffered from shango with every pregnancy, from the first month. I do not go to Western doctors ( Sendi kwa madaktari wa kizungu ). I either go myself or send for shango treatment, plus it is oral ( ni dawa ya kunywa ) instead of what the hospitals give you (meani ng vaginal suppository).

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109 Both Mwanaisha and Zubeda preferred the shango treatment and believed in its efficacy. On the other hand, the route of administ ration (oral or vaginal) was also a factor in women’s choice of treatment. At times h ealth professions did not take the time to explain the administration or listen to women’s fears or concerns about non-oral medication. Traditional herbal treatments are at times given to be inserted vaginally, but TBA and traditional healers spent more time explaining to women how to use the herbs and where to store them. Lack of privacy, a nd modesty were issues in both the storage and administration of vaginal treatment. Childbirth My nurse/midwifery experience of 20 years provided a background to evaluate births while I was in the field. I had not attended home-births and with my clinical experiences, I was not sure how I would reac t to them. This stemmed from years of working in hospitals, plus my own reservat ions and knowledge that when emergencies happen during childbirths, they take place rapi dly and have adverse effects on the mother or the baby or both. Bad outcomes happen even at the most advanced hospitals, but having the staff and equipment for appropriate and immediate care is reassuring. During my visits to birthing centers I was privileged to attend many bi rths. On one of these visits, I arrived at the same time as Faiza, a patie nt whom I had met earlier when she came for prenatal care. Faiza was a 30 year old Arab woman who was having her second baby; she was escorted by her mother and husband who both sat in the living room to await the childbirth. The time was eleven in the morni ng, and she explained that her labor pains had started at six. Before coming to the birt hing center, Faiza stated that she had been prayed for ( kuzunguliwa ) so that she would have a safe bi rth. She was in a lot of pain and had to be assisted on to the examination/ delivering bed. The nurse, Samira, examined

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110 Faiza while her assistant Zuena started to ge t the room ready for the birth. In between contractions when Faiza could communicate, she was questioned about her pains—the frequency and location—and was examine for evidence of bleeding or amniotic fluid leakage. Samira engaged Faiza in small ta lk about the family and community events. Faiza answered with difficulty due to her discomfort, but since this was not her first experience, she anticipated most of the quest ions and her answers were short but clear. From her explanation she was having regular strong contractions, three minutes apart, was having normal bleeding, and was not leak ing any amniotic fluid. On examination, Faiza was found to be halfway from deliver ing. That is, her cervix had opened five centimeters (a woman delivers when the cervix is at ten centimeters). At this moment the electricity in the center went off, but this did not dete r anybody in the room. Everyone continued with the preparation for the birt h as if nothing had changed. Kerosene lamps and flash lights were turned on. The equipment laid out was similar to what one expects to see for a normal childbirth in any hospital—that is, a tray, sterile scissors, cord clamps, gauze, cotton balls, and bowls. In addition, a supply of oxytocin (to prevent bleeding), intravenous fluids and a urinary cathete r were kept handy for emergencies. While the preparations were going on, Sa mira and Zuena encouraged Faiza to recite a special prayer calle d Suratyl Maryam from the Quran (Muslims believe this particular verse helps with la bor pains, increases distracti on and reduces anxiety). A tape recorder playing this verse was turned on a nd continued in the background since at times Samira and Zuena were in communication while they got busy preparing for the birth. As Faiza’s discomfort increased, her moaning a nd groaning at times got louder. The caregivers took turns massaging her lower back, a nd gently reminded her to revert to the

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111 recitation. She was also reminded to call to God for help through repeating “Ya Allah and Subhana-Allah”. In the private and govern ment hospitals in Mombasa where I had also attended childbirths, this type of personal attention was lacking. By twelve-thirty in the afternoon, when Samira assessed her progress, Faiza was seven centimeters dilated. Her dress was pulle d up to her chest. Two pieces of cloth ( khangas/leso) were placed under her pelvic area on top of a plastic sheet, another covered her on top, and a fourth was put on the crib to wrap the baby once delivered. This was also very different from the government hospital, where women deliver on a plastic sheet, naked, with nothing covering them. Prep arations for the birth were complete; hot water was boiling in the kitchen for later cl eaning of the mother, baby, instruments and soiled linen. By one-thirty, Faiza was ready to deliver. Samira guided her patiently, and with her legs in the lithotomy position, Fa iza delivered a healthy baby girl. Once the baby’s head was out, the baby self rotated, and after the anterior came out, Faiza was given an injection of oxytocin on her right thigh to encourage uterine contraction and to prevent bleeding. The baby was given to Zuena and taken to the cot where she was wiped and wrapped with a khanga. The placenta was delivered tw o minutes after the baby and it was checked for completeness. Pieces of the placenta that might remain in the uterus can cause postpartum hemorrhage. The perine um was checked for cuts and tears that might need suturing and there were none. Fai za had not needed an episiotomy (a cut to increase the vaginal orifice). She was clean ed, two sanitary pads were placed on her perineum to catch the bleeding, and her legs were closed and straightened. After being wiped dry, the baby was we ighed. She was six pounds, eight ounces. Faiza’s mother and husband were called in to see her and the baby. The father was asked

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112 to perform the first call to prayer for the baby. This is called the adhan – whispered in the baby’s right ear, and the ikaba into the left ear. This is an Islamic practice that is believed to prevent the baby from heari ng the call or whisper of the de vil, who misguides, and to hear instead the call of righte ousness. After this ritual, the husband congratulated his wife and left the room. He asked Samira when he should come back to pick up his wife and baby and was informed that he should return four hours later. The baby was immediately bathed, given a teaspoon of honey and Zamz am water (this is holy water brought by people who have gone for pilgrimage to Mecca) The water is believed to have blessed and healing properties. After the bath th e baby was massaged with Simsim oil, and khol (antimony) was applied to the baby’s eyes a nd given to the mother for breastfeeding. Preparation for the postpartum period ( arubaini ) began before Faiza left the center. An hour after the birth, Faiza was given po rridge made of rice flour, milk, cinnamon, cilantro seeds, sugar and black pepper. The sp ices in the porridge ar e believed to increase the body heat that was removed by the physiologi cal changes of childbirth. This practice, as explained by Manderson (1981:511), is found in most cultures th at practice humoral medicine. She adds that “childbi rth, then, depletes the mother of heat, blood and ‘air’ or vital breath, and renders he r vulnerable to cold, wind, ma gic and disease”. Faiza was covered with a blanket even though it was wa rm outside, so that she did not get cold. Two hours post delivery she was escorted to the bathroom, and the first ritual bath ( tohara ) was performed. Faiza was allowed to leave after she had urinated; this was to make sure that she did not have a full bladder, which can also cause postpartum hemorrhage.

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113 This childbirth had a good outcome, and made clear to me why women would choose such an establishment as opposed to a hospital. I observed Samira in her practice as efficient. She took time in understanding he r patients, screening them and transferring them to the hospital when conditions were out of her scope of practic e. This did not occur in some of the other birthing centers I had observed. The patience, care and attentiveness given were different from how some women were cared for in government-run maternity hospitals. The choice of a birthing location has substantial consequenc es in the resources available and in the kind of social intera ctions obtained (Jordan 1978). Obermeyer (2000: 184) observed that women in Morocco who could afford to deliver in a hospital chose to deliver at home-based birthing centers. She contends that Moroccan women see the hospital as an “unfamiliar place where they are under the supervision of strangers and where decisions about their care are made according to criteria that are often incomprehensible”. This home -birthing center had minimal biomedical specialization. Faiza was in a familial surrounding, attended by people she knew, and not leaving the environment/neighborhood she was intimatel y familiar with. Childbirth in such surroundings provided security that marked the event as a normal part of everyday life. Faiza’s husband returned a nd picked her up with the baby, and her mother. Faiza was leaving to stay with her mother for the beginning of arubaini Postpartum period ( Arubaini ) The period of 40 days after childbirth is termed arubaini which means forty in Arabic. It is a time for complete recupe ration. The concept of six weeks as the postpartum period is observed in biomedicine as well, a time where there is reversal of the physiological change s that occurred in pregnancy. In Mombasa, Arubaini is practiced by all ethnicities, though more rigidly by the Wa swahili. It is practiced in most countries

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114 that practice humoral medicine (Manders on 1981), including the Middle East, India (Goodburn et al. 1995), West Africa (Wall 1998) and North Africa (Obermeyer 2000). During arubaini women are considered weak due to blood loss and the rigors of childbirth. The woman is not allowed to c ook, clean or do normal household chores. She remains in bed, and is served hot soups (made of chicken, beef oxtail with lots of spices) so that she can sweat and get rid of body impurities. Porridge or gruels rich in milk and honey, again with more spices, are offered in between main meals to provide strength and increase breast milk for lactation. The conf inement and enclosure from the cold is to prevent loss of body heat. The remova l of body impurities through sweating is emphasized. The woman is not allowed to drink or touch cold fluids, including beverages. Bathing is with very hot water. Th e hair is not washed at least for a weak or until the initial bleeding stops. The head is cons idered the part of the body that looses a large portion of body heat. Heavy cl othes are worn to prevent heat loss. It is believed that exposure to cold air could result in deterior ation of one’s body, particularly in old age. Degenerative diseases, such as rheumatoid arthritis or weakness of any limbs are associated with exposure to cold air ( baridi ). The room in which women spend the arubaini is kept closed to prevent cold air draf ts, and a space heater or heated coals ( jiko ) may be kept in the room to provide heat. After a bath the woman stands over the fire. This “mother roasting” is done to close open skin pores and hasten closure of the open womb (Manderson 1981: 512). A masseuse comes in daily to massage the woman with warm oil to get her joints a nd uterus back in shape. A khanga or bed sheet is tightened around the abdomen as a girdle to provide back and uterine support.

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115 On the seventh day, the woman is allo wed out of bed to bathe and perform tohara. She can now move around the house, but not outd oors. Prohibitions of activities restrict her leaving the home except in an emergency. If a son is born, the baby will be taken for circumcision by a relative and two unblemis hed goats are slaughtered. For a daughter, one goat is slaughtered and a small feast is prepared for thanksgiving. Babies born at home are taken by a relative to the health department for registration and weighing and first tuberculosis prophylaxis. During these fo rty days, the baby is given a half a teaspoon of honey mixed with pure ghee daily for strength. To remove hasad a black amulet is tied on the baby’s arm or around the neck. Insi de a piece of a Quranic verse or a small piece of a special bark ( mvuje ) (which has a pungent smell) with cardamom seeds (which have a sweet smell) and black pepper is used for the same purpose. All these rituals are aimed at soliciting divine assistance and warding off mi sfortune (Sered 1994). During this period, the woman spends time at her parent’s or in-laws if the parents do not live close. Women at times travel during the last trimester to the home where they will be in arubaini Financial or other logistic arrangeme nts of travel are done early in the pregnancy to facilitate the travel of the woman to where she will be in arubaini The husband visits and provides for the wife and her family during the duration of her stay away from home. The movement of the woman away from her residence to her parent’s home interferes with prenatal care or me dical follow-up unless previously arranged. Odile (1983:140) cautions that a long period of postpartum abstinence encourages the sexual mobility of men (including extramarital sex, divorce, polygamy and visiting of prostitutes) and is associated with an increased incidence of sexually transmitted infections that can lead to infertility.

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116 Some women will attend prenatal care services close to where they will be in arubaini This provides continuity of medical and obstetrical care, particularly if there had been any previous problems. I interv iewed women who worked outside the home who did not leave their homes for arubaini. However, some women left from the seventh month of their pregnancies and six weeks after delivery and they had not returned to their marital homes. For some women, prenatal car e is not continued when they leave for arubaini Other women, on the other hand might rest art with a private physician or go to the nearest health department. Since record s are not usually taken, the new clinician might not be aware of the woman’s obstetric al problems. Some husbands complained of this cultural separation, especia lly due to the expense of taki ng care of two homes, plus disruption of their marital relationship. Arubaini was a time of rest and a break from daily hard work and routines, esp ecially for those who compla in of in-laws who overwork them. Return to routine chores is slowly resume d after three to four weeks or for some women the whole forty days. On the fortieth day, if the woman left her marital home, she performs tohara again. She is also decorated with henna tattooing on her hands and feet. She and the baby are dressed in new clothe s and are escorted to her marital home. Arubaini is not practiced by all Mijikenda group s; different rituals take place after the third day. On the third day, the baby’s gr andmother throws wate r on the roof of the house and the baby is kept in an open basket ( uteo ) below the roof where the water will drip. This exposure I was informed was to ma ke sure that the baby does not fear rain drops. After this experience, the baby is pl aced on the mother’s back. The woman is given an axe and has to chop a small piece of firewood; this is to teach her how to chop

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117 firewood with a baby on her back. For the rest of the month small chores are reintroduced daily, all done while she is either breastfeedi ng or carrying the baby. This process continues until she is strong enough to return to full work in the fields. Simultaneously, some of the other rituals, such as hot foods, hot baths and body massage are performed.

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118 CHAPTER 7 SUMMARY AND CONCLUSION Introduction Across the world, public health indices reflect social and economic indicators (Gupta et al. 2003). The impact of poverty is particularly st rong on women’s health (see for example, Glanz et al. 2003) and on the health of the childre n they bear (see for example, Garcia-Gil 2004, Grjibovski et al. 2002, Kaplan et al. 1996). Efforts to improve the health of women and infants must address the causes of poor health. In this chapter, I apply a cultural materialist framework to anal yze the findings of this research. “Cultural materialist theoretical princi pals are concerned with th e problem of understanding the relationship among the parts of socio-cultural systems and with the evolution of such relationships, parts and systems” (Harris 2001 : 71). The organization of this chapter follows the infrastructural, structural and ideological factors on which women’s health appears to depend. The specific infras tructural factors include demography, transportation, and reproductiv e technology. According to Ha rris, the infrastructure shapes the structure (class, ethnic, family structure, domestic and political economy) which in turn influences people’s ideology. A materialist framework includes culture as an important determinant of healthseeking behavior in any soci ety since the assumptions (based on different kinds of knowledge) about the causes and treatment of illness differ between lay people and health care professionals. These assumptions change over time as culture responds to changes in the other components of societ y. Chavez et al. (1995), for example, found that Latinas’

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119 understanding of the causes of breast cancer were increas ingly similar to those of physicians in the United States the closer the women were to U.S. culture. The folk models of Salvadoran and Mexican women we re furthest from that of physicians; those of U.S. born Chicanas overlapped with t hose of Mexican women and Anglo women; and those of Anglo women resembled most those models of physicians. Demographic and Obstetrical Determinants of Health Care Age is an important factor in reproduc tive health. Lack of education and early marriages means early pregnancy with its many probable hazards. Girls under fifteen may face five times the risk of death in pregnancy and childbirth which women aged 2024 years face, and the risk remains twice as high for girls between fifteen and nineteen (UNICEF 1991: 30). Girls who ar e not HIV infected or sexua lly active are particularly prized as wives and mothers at their ve ry young age. For these young mothers and their children, expanded health edu cation is critical, with em phasis on health education, knowledge about contraceptives, birth sp acing and other safe motherhood practices. Unlike many parts of Kenya, people in Mombasa are extremely heterogeneous, (Chapter 2) making ethnicity an important co mponent to consider when assessing health care. Given this heterogeneity, provision of heal th care has to take in to account how risk is defined by particular groups, and the strategies that women, men, healers and healthcare providers use to address or counter act risk (Allen 2002). For example, beliefs held by the Mijikenda about the preventative care that a pregnant woman needs are not shared by other Waswahili. As well, et hnic groups are not bounded entities—both patients and healers frequently cross lines in how they receive or provide health care (Good 1986). Educating a particular group about health care requires understanding the knowledge and beliefs of that group.

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120 Women in Mombasa share with women ev erywhere the respons ibility of looking after their family, including, at times, a very extended family. Women’s chores are burdensome and may include work in both the formal and informal sector. Most women do not have help or labor sa ving devices, which makes daily chores both time-consuming and exhausting. Women are pulled in many dir ections leaving them exhausted and not having enough time to take care of their health. The women in Mombassa whom I studied, like women across the developing world, worried about the ava ilability of basic necessities, like electricity and water that are taken for granted in the industrialized world. The effort and time spent on getting a nd maintaining these ba sics prevent women from spending needed time on preventative health care practices. The majority of women who work outside the home are employed as secretaries, teachers, nurses and clerks—occupations at th e lower rungs of the occupational ladder. An increasing number of women are involved in the informal sector in a wide range of micro-enterprises to supplement their income s. I observed women traveling as far as the Middle East to buy goods such as, gold and perfumes to sell to other women in homes. Women who have sufficient econo mic independence and social status also have control over their sexual and reproductive lives and do no t allow mere fate to dictate their health. Women’s increased income makes accessibility to resources such as health care and education possible. As stated by Handwerk er (1989: 15) “Changes in women’s power relationships are predicated on fundamental ch anges in women’s ability to gain access to resources”. Women use financial independence to educate their child ren and to provide health care for themselves and for their families. The competition into the world economic system has developed “social conflict and depersonalization of social relations”

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121 (Bernard In Handwerker (1989: 9) such as increased divorces and more female headed households. Women’s duties, of course, include ch ildbearing and mothering. Pregnancy and childbirth is supposed to be a family’s happiest moment, but for some women, it is obviously not. Good health prior to and dur ing pregnancy increases a woman’s chances of surviving a pregnancy-related complicati on, while conditions such as anemia create and exacerbate complications of pregnancy. Anemia is the co nsequence of poor intake of foods rich in iron and protein. Women in mo st developing countries where food is scarce eat after the rest of the family has eaten. Another problem that affects almost all women in Mombasa is malaria. Malaria in pregnant women can be a major cause of anem ia, resulting in death in utero or in low birth weight babies. The use of mosquito nets and prophylacti cs works to prevent malaria but resources for programs that provide thes e are scarce nationally and are beyond the means of many poor women locally. Even women who attend prenatal care services may not be given iron and/or mala ria prophylactics because these items are not available. Another problem is lack of regimen complia nce, so that iron supplements and antimalarial medications are not taken prope rly (see Chapter 6). Recommendations to improve women’s nutritional status and their resistance to dis eases have to be developed through counseling during prenatal care and po stpartum visits, and delivered nationally through media campaigns. Kenya has come a long way in anti-malaria campaigns; however more education is now needed in the use of over-the-counter anti-malarial medications like chloroquin and chamoqui n. I observed pregnant women who thought they might have a fever (homa) buying and ta king a course of th e above pills without

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122 diagnosis or testing for malaria. Secondary infertility was cited as a problem by almost one in four women. Family planning efforts have concentrated on reducing the number of children, not on assisting those who have in fertility problems. Wo men who considered infertility to be an issue, shopped for h ealers who would listen to their problem and provide care. They found traditional healer s more receptive to their problem than biomedical clinicians. Women need to f eel secure and confident when seeking biomedical care for infertility. The majority of women do not receiv e postpartum care if the delivery is uncomplicated. Babies are taken for a well-baby check-up (for weighing and immunization) by other family members. Wo men need postpartum checks to make sure they are healing after deli very, and they need counseling on breastfeeding, weaning, nutrition, contraceptives, perine al exercises, baby care, ca ncer screening and STI/HIV prevention. HIV infected women are often first iden tified in reproductive health settings mostly related to other STIs. These women n eed counseling about HI V-related issues in pregnancy. Information should be consis tent and repeated with patience and confidentiality. These women ma y have other problems that need to be addressed, since they are prone to domestic violence or divorce (Chapter 3). In Mombasa, the majority of women tested for HIV do not go back for resu lts for fear of findi ng out that they are positive, knowing that counseling and treatm ent may not be available. Health care providers as well withhold information when they know that there are no antiretrovirals that the patient can afford. The general messages of HIV prevention and transmission have been successful in the community. However, emphasis on the importance of

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123 choosing a birthing facility that can reduce MTCT has not been emphasized. The results from this study will be shared with clinic ians and HIV/AIDS pr evention advocates in Mombasa. Household Characteristics and the Domestic Economy “Family and household characteristics, su ch as co-residence with in-laws and the nature of the household economy, affect th e balance of power and use of [health] services” (Blanc 2001: 192). In such fam ilies (Chapter 5) a young woman’s labor and mobility is managed or controlled by the se nior women and men in the household (Morsy 1993). Since attending prenatal care is a prev entative measure, women who attend most of the assigned visits may be criticized or accused of laziness and using services as an excuse to slack off from their home duties. Most of the women I interviewed in these families said that they had to finish their designated chores and then ask for permission before going to the health department. Sometimes there was simply not enough time to finish the house work and attend prenatal care services. The services are offered at most health departments only three mornings a wee k. At times the husband is not the person in authority. He may also be subordinate to his older brothers, mother or father, whom he tries not to displease so as to avoid fam ily dissension. A woman who has the backing of her kin or has an education and/or income can be more vocal in deci sions either directly or through her relatives. However, most of the time, relatives are the therapy managers and decide where and when a woman can seek health care. Within households, women were concer ned about the accepted practice of polygyny. In polygynous homes women and chil dren are often economically and emotionally disadvantaged. Women are left to fend for themselves and their children, depending on the husband’s time arranged betw een co-wives or households. The sharing

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124 of limited resources, love and attention cr eates an unhealthy competition between the women which causes stress and anxiety. Some women accepted their husbands taking a second wife, particularly in instances of in fertility (Chapter 6). Polygyny impedes further the effort to decrease STIs and HIV. Men’ s sexual mobility (Chapter 6) means that multiple wives are at risk of infection. Local and State Political Economy and Health Care More recently, programs in Mombasa to better women’s health and to reduce STIs and HIV/AIDS have also targeted me n. Community based seminars in the Muslim community are encouraged with assistance fr om international NGOs, such as Pathfinder International and UNAIDS. These groups have targeted the Supreme Council of Kenyan Muslims (SUPKEM) at the Council’s headquarters in Nairobi and Mombasa and elsewhere across the country, and have included all imams and preachers in the prevention programs. The imams and preachers in Mombasa have become the proponents who assist in disseminating information on re ligious and socio-cultural practices that affect societal health. Issues such as early marriages, the secular and religious illiteracy of women, divorce, polygyny, HIV/AI DS, and female genital surgeries are now openly discussed, particularly with regard to thei r effects on women and methods to decrease their prevalence. These same NGOs have added obstetrical health issues as a community concern. One of the agendas is to identify and acknowledge non-biomedical health care givers, like traditiona l birth attendants. Traditional birth attendants in Kenya are not recognized as part of the formal health care sector, although in most parts of the country they provide more services than do the biomedical professionals. In addition, the government has not taken a strong lead in incorporating TBAs into the formal health care sector. Their incorporation into the

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125 health sector would be benefi cial since they can then be supervised and better trained. TBAs can be encouraged to keep a simple di ary to record the numb er of pregnant women seen, referred and delivered. This diary can be presented to the chief with notes about the outcome of deliveries: date of birth, sex of the baby, birth injuries, and condition of the mother after delivery. TBAs whom I interviewed said that they were receptive to the idea of advice and assistance from the official h ealth sector. Presently, almost half of the births in Mombasa are unrecorded. The collect ion of women’s health statistics will not be complete without the inclusion and traini ng of TBAs (Ayiemba and Mogere 1999: 23). Even with incorporation of TB As, however, the critical fact or in averting morbidity and mortality in pregnant women is the availabil ity of advanced health services to care for women with complications. Unfortunately, the health car e facilities in Mombasa often lack essential drugs, supplies and equipment. They may lack competent staff, and there is often delay of services and errors in diagnosis and treatme nt. Just 30% of Kenya’s health care budget is allocated to prevention and 70% is allocated curative care (Owino 1997: 11). In addition to financial problems, Kenya’s health car e services suffer from managerial and organizational problems which have adversely affected the availability of quality public health services. It is gene rally accepted that the essence of progress in a country is improving the quality of life, including ex tending longevity and reducing infant mortality. For this to happen in Kenya, mo re public resource s (through donor support) need to be directed to preventative health care services (ibid). Over-concentration of facilities, both private and public, results in competition and inefficiencies in the delivery of health services. The government and pr ofessional body that should enforce minimum

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126 standards of care, particularly in the urban areas, barely ex ist. Moreover, even the poor service available is out of reach for many wo men because of cost (Chapter 5). In their study of health care cost, Owino and Were ( 1998) examined waivers and exemptions for vulnerable individuals who cannot afford health facility cost s, and suggested the pooling of revenues to subsidize those least able to pay. In Kiswahili there is a saying, cha bure chaumiza (what is free hurts). Women invoke this saying when free health care services are offered. The saying also implies that wome n do not want or expect free services but do want to pay for worthwhile services. Another saying is vipi unisumbue na pesa yangu? (how can you frustrate me with my ow n money?) This question emphasizes that women will demand better services or shop elsewhere when not satisfied. Culture and Women’s Health Beliefs Cultural beliefs are not static. Attitudes and practices that disadvantage women’s health can and do change in favor of thos e which “accept and promote the universality of human dignity and rights, regardless of gender” Odaga (1994: 27). In this study I portray culture as an important component for understanding women’s health problems. Initiation to womanhood with female genital mutilations (FGM) creates immediate health risks and trauma that are harmful during pregnancy a nd parturition. Some form of FGM is still practiced widely among Muslims in Africa (Toubia and Sharief 2003). There is some evidence that public opinion is turning against the practice, but the shift is slow and depends on women having the power to reject it. This, in turn, depends on larger, macro social changes. However, other practices such as those of the somo/mwari (see Chapter 6), where an older woman teaches an initiate (without surgery), can be adapted to ensure be tter health practices. If the somo has knowledge about good health practices, she can pass the information to her mwari beginning a generation of

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127 knowledgeable women. Knowledge, however, does not produce behavioral change without the power to do so and the power in this case is financial independence for women, just as it has been the engine of the second demographic transition. In Mombasa, I observed an increased sh aring of cultural practices, for example Somali women have learnt and adopted from Arab women a different way of practicing female circumcision. Somali women who practic e infibulation (which is the extensive removal of a girl’s clitoris, labia minora a nd part of the labia majora or type 3) as sunna or Muslim religious directiv e learn from other Arab Mus lim women who practice partial clitoroidectomy (type 1) (C hapter 6) Although both prac tices produce physical and psychological trauma, there is less physiological damage with type 1 than with type 3. This decreased injury prevents further trauma during childbirth. Moreover, the nonMuslim communities do better in terms of preven tative maternal/child health care, which the Muslim community is now emulating. This relevant behavior whic h is contributing to better health is shaped by nor ms and routine activities, which are even more adopted with women with secular educati on. It is a known fact that schooling is an influential component of health worldwide. The education of girls in Mombasa, like most other parts of Kenya has not been a priority (Chapter 5) As of this year 2005, primary or elementary education has just been made free to encourage school atte ndance in Kenya. The presence of Muslim girls in secondary and the univers ity is gradually increasing due to community and varied motivators. Education is not the only factor that creates social change. Social change is a long-term process that involve s a few generations a nd begins when women autonomously have and control their own income. Bernard (In Handwerker 1989: 8) states that, “women’s status is low when they optimize their access to resources by

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128 relying on their husbands, pare nts, and children; women equa lize their power, relative to their parents, their husbands and their children to the extent that they are free to gain access to resources independently”. I left Mombasa twenty years ago when I was part of the health care system. During this revisit I saw a major deteriorati on of health care faci lities and poor care particularly in the government/municipal heal th departments, which most women depend on. On the other hand, health car e facilities have mushroom ed all over the island. Some provide decent care while others offer medioc re care for profit. I was pleased to observe the involvement of women who are more pro active in questioning su bstandard services and at times not accepting what is offered. Despite the various challenges faced by women, there are dramatic positive changes as a result of new opportunities in education, labor force participation, women’s group activit ies, legal reforms and a variety of other initiatives both in Mombasa and at the natio nal level (Suda 1999: 6). Handwerker (1989: 31) argues that health care providers and organizations ar e the “gatekeepers” and have power and therefore access to health care. In th e same vein, he asserts that “virtually no one is without power”. Women with resource s are using their power to improve health care access and consequently their lives. Swahili culture also accepts the idiom “prevention is better than cure” ( kheri nusu shari kushinda shari kamili ). In addition, as a result of advances in information tec hnology, women in Mombasa, like those all over the world are in the process of changing in different ways and in their behaviors accordingly to improve their lives.

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129 APPENDIX A DEMOGRAPHIC CHARACTERISTICS Figure A-1. Percentage of respondents by ethnicity

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130 Figure A-2. Respondents' le vel of secular education

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131 Figure A-3. Respondents' knowledge about mother-to-child HIV transmission

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132 Figure A-4 Respondent’s knowledge of at least one possible method of motherto-child transmission.

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133 0 10 20 30 40 50 60 70 80 90 123456789 Month of beginning prenatal careFrequency Figure A–5. Month biomedical prenatal care started

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134 Figure A. Respondents' number and fr equency of prenatal care visits

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135 Figure A. Percentage of respondents choice of birthing facilities

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136 Descriptive statistics fo r independent variables Table A-1. Section A Demogr aphic characteristics Variable N % Number of respondents 265 Mean age of respondents 26 Range 16-47 16-20 44 16.6 21-34 204 76.98 35-47 17 6.4 Ethnic affiliation Arab 71 26.8 Swahili 14 5.3 Indian 7 2.6 Mijikenda 80 30.2 Bajuni 47 17.7 Jomvu/ Changamwe 4 1.5 Somali/ Ethiopian 17 6.4 Others 25 9.4 Education None 31 11.7 Elementary 142 53.6 Secondary 89 33.6 Trade 1 0.4 College 2 0.8 Islamic education None 17 6.4 Basic 39 14.7 Elementary 146 55.1 Advanced 63 23.8 Occupation Housewife 139 52.5 Teacher 11 4.2 Accountant 7 2.6 Secretary 15 5.7 Sales 56 21.1 Seamstress 15 5.7 Hairdresser 8 3.0 Other 14 5.3

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137 Table A-1. Continued Variable N % Marital Status Single 1 0.4 Married 257 96.9 Divorced/ Separated 5 1.9 Widow 2 0.8 Marital Union Monogamy 228 87.2 Polygamy 29 10.9 Missing data 8 3.0 Obstetric characteristics Number of children One 44 16.6 Two 66 24.9 Three 25 9.4 Four 12 4.5 Five or more 19 7.2 Number of miscarriages One 23 8.7 Two 6 2.3 Three 5 1.9 Four 1 0.4 Number of stillborns One 11 4.2 Two 2 0.8 Three 1 0.4

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138 Table A-2. Section B H ousehold characteristics Variable N % Spouse/Partner’s education None 4 1.5 Elementary 85 32.1 Secondary 153 57.7 Trade 4 1.5 College 11 4.2 Not sure 3 1.1 Partner’s Islamic education None 12 4.5 Basic 17 6.4 Elementary 103 38.9 Advanced 122 46.0 Not sure 6 Partner’s Occupation Driver 66 24.9 Shopkeeper 18 6.8 Clerical work 46 17.4 Carpenter 3 1.1 Businessman 42 15.8 Salesman 24 9.1 Builder 13 4.9 Other 39 14.7 Unemployed 6 2.3 Not sure 8 Medical Insurance Yes 60 22.6 No 197 74.3 Not sure 2 Insurance type National hospital insura nce fund (NHIF) 57 21.5 Other 4 1.5 Not sure 3 Home ownership Yes 117 44.2 No 148 55.8

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139 Table A-2. Continued Variable N % Rent homes Yes 136 51.3 No 129 48.0 Given/ company homes 12 4.5 Available tap water Yes 226 85.3 No 39 14.7 Buy water Yes 76 28.7 No 189 71.3 Electricity in home Yes 244 92.1 No 21 7.9 Car ownership Yes 33 12.5 No 232 87.5 Telephone ownership Yes 175 66.0 No 90 34.0

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140 Table A-3. Section C – Knowledge of mother-to-childHIV transmission Variables N % Aware of transmission Yes 249 94.0 No 4 1.5 Not sure 12 4.5 Source of information Word of mouth 41 15.5 School/ college 25 9.4 Health care provider 113 42.6 Media (radio, TV, newspapers, magazines) 245 92.5 Respondents tested for HIV Yes 189 71.3 No 76 28.7 Knowledge of transmission In utero 207 78.1 Childbirth 185 69.8 Breastfeeding 160 60.4

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141 Table A-4. Use of maternity health care Variable N % Prenatal care initiation at biomedical facility None 7 3.0 First month 6 2.3 Second 14 5.3 Third 33 12.5 Fourth 50 18.9 Fifth 80 30.2 Sixth 46 17.4 Seventh 21 7.9 Eighth 8 3.0 Number of visits None 7 2.6 Less than six 57 21.5 Six 20 7.5 More than six 181 68.3 Advisors to initiate biomedical prenatal care Self 39 14.7 Husband 136 51.3 Mother 41 15.5 In-laws 33 12.5 Friend 11 4.2 Other 5 1.9

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142 Table A-4. Continued Variable N % Transportation Walk 60 22.6 Drive 6 0.6 Public transportation 186 70.2 Taxi 2 0.8 Reasons for using a biomedical facility Islamic institution 31 11.7 Distance 83 31.3 Health care provider/s 115 43.4 Cost 101 38.1 Services 186 70.2 Health problems 18 6.8 Reasons for not using a biomedical facility Long waiting period 43 16.2 Health care provider/s 45 17.0 Distance 22 8.3 Services 28 10.6 Cost 27 10.2 No response 7 Choice of childbirth facility Homeno assistance 3 1.1 Home with a traditional birth attenda nt (TBA) 34 12.8 Home with clinician 22 8.3 Level – 1 hospital 88 33.2 Level – 2 hospital 60 22.6 Level 3 hospital 58 21.9

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143 Table A-5. Logistic regression model results of the determinants of using prenatal care Odds of using prenatal care by women who reported using biomedical facilities Variables df OR p-values Respondent’s education 2 0.112 0.0011*** Partner’s Islamic education 3 0.227 0.0654* Telephone ownership 1 0.162 0.0114** Knowledge of HIV transmission (in utero) 1 0.188 0.0313** Number of miscarriages 1 0.575 0.0344** Islamic institution 1.072 0.8828 ns Distance 1.742 0.0836* Health care provider/s 1.151 0.6536 ns Cost 1.619 0.1751 ns Services 2.326 0.0211** Health problems ***p < 0.01, **p < 0.05, *p < 0.10 ns=not significant

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144 Table A-6. Logistic regression model odds of choosing of a bi rthing facility as reported by respondents Variables df OR p-values Ethnicity 6 12.173 <0.0001 *** Insurance 1 0.282 0.0008 *** Education 2 0.013 0.0194 ** Tested for HIV 1 0.033 0.0119 *** Knowledge of MTCT (in utero) 1 0.218 0.0001 *** Previous childbirth 1 0.286 <0.0001 *** Education and HIV test 2 1.112 0.0329 ** Previous childbirth and HIV test 1 2.977 0.0009 *** Islamic institution 1.500 0.3447 ns Distance 1.776 0.0657* Health care provider/s 1.822 0.0336 ** Cost 3.642 < 0.0001 *** Services 0.587 0.1252 ns Health problems 0.479 0.2165 ns ***p < 0.01, **p < 0.05, *p < 0.10 ns=not significant

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145 APPENDIX B QUESTIONNAIRE 1. Interview code (ID): ________ Date _________ 2. Interviewer _______________ Section A Demographic Questions 3. Age _____ 4. Ethnicity ______________ 5. Marital Status ___________ Single (1) ___________ Married (2) ___________ Common law (3) ___________ Divorced/ Separated (4) ___________ Widow (5) 6. Marital Union Monogamy (1) ______ Polygamy (2) ______ 7. Husband’s residence? __________________________ 8. Do you work? Yes (1) ______ No (0) _____ 8a. What is your profession? __________________________ 8b. Do you have medical insurance? Yes (1) ______ No (0) 9. What is the highest grade you have completed? ___Grade ___class ___none 10. Did you attend Islamic schooling? ____ Yes (1) _____ No (0) ____ 10a. How many years? ________ 11. Are there any children in your house hold who are in school? ___Yes__No(0) 11a. Which school do they attend? ______________________________ 11b. Do the child/ children attend madrasa? _____ Yes ____ No 11c. How frequently? ____________________ Section B Household Characteristics 1. Does your husband work? Yes (1) ____ No (0) ______ 1a. What is his profession? ___________________________

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146 2. Does he have any type of medical insurance? Yes (1) ____ No (0) ____ 2a. What type? ________________________________ 3. What is your husband/partner’s hi ghest grade completed in school? ______ grade _____ class _____ none 3a. Did your husband/partner attend Isla mic schooling? Yes (1) ___ No (0) ____ 3b. How many years? ___________________ 4. How many adults live in your home? ______ 4a. How many work? _______ 5. Your house is ____ rented (1), ____ owned (2), ____ given (3) ___ other (specify) (4). 6. Do you have running water in your house? ____ Yes (1) ____ No (0) 6a. Do you buy water? ____ Yes (1) ___ No (2) 6b. Do you have a water tank? ____ Yes (1) ____ No (2) 6c. Do you use well water? ____ Yes (1) ____ No (2) 7. What kind of a toilet do you use? ____ pit latrine (1) ____ flush toilet (2) _______ other (3) 8. Do you have electricity at home? ____ Yes (1) ____ No (0) 9. Do you have a phone (mobile/cellular) ____ Yes (1) ____ No (0) 10. Do you own a car? ____ Yes (1) ____ No (0) Section C Knowledge of mother -to-child HIV transmission Please tell me what you know about mother-to-child HIV transmission 1. Do you know that a baby can get HI V from the mother? ____ Yes (2) ____ Not sure (1) _____ No (0) 2. If yes to the above, how did you get the information? ___________________ 2b. Does this information change how seek maternity health care Yes ___ No ___ 3. How do you think babies get HIV? ____ in utero, ____during delivery, ___ while breastfeeding. Section D Maternity health-seeking behavior 1. Do you have children? ____ Yes (1) ____ No (0) 1a. If yes, how many? ______ 1b. Have you had any miscarriage/s _____ Yes (1) ____ No (0)

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147 1c. Have you had a stillbirth/s? _____ Yes (1) ____ No (0) 2. When is your due date? _______ 2a. Have you started prenatal ca re? _____ Yes (1) _____ No (0) 2b. If yes, where? ____________________________ 2c. How many visits have y ou made so far? _____________ 2d. If no, why not? _____________________________ 2. Did anybody help you decide when to start prenatal care? ____Yes (1) ___ No (0) 3a. If yes, whom? __________________________________________ 3b. If no, whom? ___________________________________________ 4. Did anybody discourage you from seeking prenatal care? ____ Yes (1) _____ No (0) 4a. If yes, whom? ____________________________________________ 5. Where do you live? ________________________________________ 5a. How do you get back and forth from the clinic? ____________ Walk ____________ Drive ____________ Public transportation ____________ Taxi 6. Do you like the health care center you are attendin g?____ Yes (1) ____No (0) 6a. Why do you like it? ____________________________________ 6b. Why don’t you like it? __________________________________ 6c. Why did you choose this partic ular health care center? _________________ 7. Have you decided where you are going to deliver your baby? _____ Yes (1) _____ No (0) 7a. If yes, where? ___________________________________ 7b. If no, why not? __________________________________ Section E Health care decision – making process I am going to provide different conditions or situations, and I want you to tell me what you would do or where you would seek care. 1. Have you been sick with this pregnancy? _____ Yes (1) _____No (0)

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148 2. If yes, what did you suffer from? ______________________________ 3. How long did the sickness last? __________________________________ 4. Was the sickness diagnosed? _____ Yes (1) _____ No (0) 4a. Who diagnosed the illness? _____________________________ 4b. If yes, what was the diagnosis? ___________________________________ 5. How and where did you seek treatment? _____________________________ 6. How long did the treatment continue? ___________________________ 7. What treatment was effective? ________________________________ 8. When did you consider healed? ________________________________ 9. Have you been sick with a previous pregnancy? ____ Yes (1) ____ No (0) 10. If you do not feel well while pregnant, what would you do first, _______________ and then, _________________________, if you do not get better ___________________________ 11. Tell me how you would treat anemia, first ___________________ then _____________________, and if no relief ___________________________ 12. How about a fever, first _______________________, then _____________________ and if no relief _____________________________ 13. How about high blood pressure, first _________________________ then ___________________ and if no relief ____________________________ 14. How about body aches, first ____________________________, then _________________ and if no relief____________________________ 15. If your “water” breaks what w ould you do first __________________, and then ________________________ 16. If you started labor pains, whom would you first tell? ____________________ 16a. Why? __________________________________________ 17. When do you think is the appropri ate time to go to the hospital? ____________ 18. How would you get to the hospital if there were a problem? _________________

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149 APPENDIX C CODING FOR QUESTIONNAIRE Table E-1. Coding for Questionnaire SECTION A Demography Variable Name/Code Variable Description 1-3 Infonumb Informant number 001-265 4-5 Age Age in years as reported by informant 6-7 Ethncity Ethnicity of the informant, Codes: 1 – Arab 2. Waswahili 3. Indian – Bulushi, Kochni, Bohra 4. Mijikenda – Digo, Duruma, Rabai, Giriama 5. Bajuni 6. Wajomvu/ Wachangamwe 7. Somali 8. Others 8-9 MrtlSt Marital Status of Informant 1. Single 2. Married 3. Common law 4. Divorced/Separated 5. Widowed 10-11 MrtlUn Marital Union of informant 1. Monogamy 2. Polygamy

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150 Table E-1. Continued SECTION A Demography Variable Name/Code Variable Description 12-13 SPSRES If in a polygamous re lationship, how are the days spent between each household by spouse 1. One day 2. Two days 3. Three days 4. One week 5. Other If in a monogamous relation, but works out of Mombasa, also indicate by placing a 5. 14-15 WRKSTUS Occupation of the informant. 1. Housewife 2. Teacher 3. Accountant 4. Secretary 5. Saleswoman 6. Seamstress 7. Hairdresser 8. Other 16-17 MEDINS If informant has medical insurance coverage 0. No 1. Yes 18-19 EDUC Highest level of education completed 1. None 2. Primary 3. Secondary 4. High/ Trade school 5. College 20-21 ISLEDUC Islamic education completed 1. None 2. Basic (<5years) 3. Elementary (10-15 years) 4. Advanced (16 and more)

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151 Table E-1. Continued SECTION B Household characteristics Variable Name/Code Variable Description 22-23 SPSOCC Informant’s spouse or partner’s occupation 1. Driver 2. Shopkeeper 3. Clerical 4. Carpenter 5. Businessman 6. Salesman 7. Builder 8. Other 9. Unemployed 24-25 SPSMINS If spouse’s job provides medical insurance 0. No 1. Yes 26-27 INSTYPE Type of insurance provided 1. NHIF (national hospital insurance fund) 2. other 3. not sure 28-29 SPSEDU Highest level of education completed by spouse or partner 1.None 2. Primary 3. Secondary 4. High/ Trade school 5. College 30-31 SPSISLED Spouse’s or partner’s level of Islamic education 1. None 2. Basic (<5years) 3. Elementary (10-15 years) 4. Advanced (16 and more)

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152 Table E-1. Continued SECTION B Household characteristics Variable Name/Code Variable Description 32-33 34-35 36-37 OWNHOM RNTHOM OTHER Socioeconomic status will be based on, Home ownership, 0. No 1. Yes Rental of home, 0. No 1. Yes Individuals whom neither own or rent the home, example those living in family, or company homes, 0. No 1. Yes 38-39 40-41 AVLWTR BUYWTR Availability of water in the household, functioning tap water or well water, 0. No 1. Yes Individuals who have to buy water from neighboring water sources, 0. No 1. Yes 42-43 ELCTHM Having electricity in the house, 0. No 1. Yes 44-45 YSCAR Ownership of a car, 0. No 1. Yes 46-47 TLPHME Ownership of a telephone, 0. No 1. Yes 48-49 ADHSH Number of adults in the household, 1. 1 2. 2 3. 3 4. 4 5. 5 Other

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153 Table E-1. Continued SECTION C Knowledge of MTCT Variable Name/Code Variable Description 50-51 KMTCT If informant has knowledge that a baby can get HIV from the mother, (2) Yes (1) Not sure (0) No 52-53 TFHIV Has informant been tested for HIV, (0) No (1) Yes 54-55 56-57 58-59 60-61 YKMTCTA YKMTCTB YKMTCTC YKMTCTD Informant’s source of information, 1. Word of mouth in the community (0) No (1) Yes 2. School/college (0) No (1) Yes 3. Healthcare provider (2) No (3) Yes 4. Media (radio, TV, newspaper) (4) No (5) Yes 62-63 KCHMHB If knowledge of MTCT change the informant’s maternity health-seeking behavior, (0) No (1) Yes

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154 Table E-1. Continued SECTION C Knowledge of MTCT Variable Name/Code Variable Description 64-65 66-67 HIVTRBU HIVTRBR Informant’s opinion of how babies contract HIV, 1. In utero (0) No (1) Yes 2. While breastfeeding (0) No (1) Yes 68-69 HIVTRDEL If informant has knowledge that babies contract HIV during delivery, 0. No 1. Yes 2. Not sure 70-71 CHILD Does informant have children, (0) No (1) Yes 72-73 YCHILD If yes to having children, how many, 0. None 1. One 2. Two 3. Three 4. Four 5. > five 74-75 MISSCAR If informant has had a miscarriage, (0) No (1) Yes 76-77 YMISSCAR If yes to the above, 1. one 2. two 3. three four

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155 Table E-1. Continued Section D Maternity Healthseeking Behavior Variable Description 78-79 STILLB If informant has had a stillborn, (0) No (1) Yes 80-81 YSTILLB If yes to the above, how many, 1. one 2. two 3. three 82-83 BIGPNC When did the informant begin prenatal care, 0. None 1. less than 5 months 2. 5 months 3. Sixth 4. Seventh 5. Eight 6. Ninth 84-85 NUVISIT Number of prenatal care visits made with documentation, 0. None 1. less than 6 2. six 3. more than six 86-87 RNOPNC Reasons given for not seeking prenatal care, 0. None 1. Not sick 2. Not necessary 3. Too far 4. No transportation 5. No money 6. Housework 7. Relocate (either due to h.c.p or respondent) 8. Other

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156 Table E-1. Continued Section D Maternity Healthseeking Behavior Variable Description 88-89 PNCADV Individual who assisted informant with prenatal care decision making, 0. Self 1. Husband 2. Mother 3. In-law 4. Friend 5. Other 90-91 DISCPNC Has anyone discouraged informant from seeking prenatal care, (0) No (1) Yes 92-93 TRNSPRT Informant’s means of transportation to health care center, 1. Walk 2. Drive 3. Public transportation (matatu) 4. Taxi 94-95 96-97 98-99 100-101 102-103 HCLYKSA HCLYKSB HCLYKSC HCLYKSD HCLYKSE Reason/s given for choosing a health care center, 1. Islamic institution (0) No (1) Yes 2. Distance (0) No (1) Yes 3. Health care providers (0) No (1) Yes 4. Affordable/Cost (0) No (1) Yes 5. Health care services (0) No (1) Ye

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157 Table E-1. Continued Section D Maternity Healthseeking Behavior Variable Description 104-105 HCLYKSF 6. Health problems (0) No (1) Yes 106-107 108-109 110-111 112-113 114-115 HCNEGA HCNEGB HCNEGC HCNEGD HCNEGE Informant’s negative opinion/s concerning health care centers, 1. Long waiting period (0) No (1) Yes 2. Health care providers (0) No (1) Yes 3. Too far – distance (0) No (1) Yes 4. Inadequate facility (0) No (1) Yes 5. Payment for services No (1) Yes 116-117 CHODEL Informant’s choice of delivery center, 1. At home – no assistance 2. At home – with TBA 3. Home – nurse/midwife/physician 4. Level 1 hospital (a level 1 hospital provides immediate care to the mother and basic care to the baby) 5. Level 2 hospital (a level 2 takes care of emergencies to both mother and baby) 6. Level 3 hospital (this includes advanced care to both mother and baby)

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158 LIST OF REFERENCES Abdalla, Ismail (1992) Diffusion of Islamic Medicine in Hausala nd. In The Social Basis of Health and Healing in Africa. Steven Feierman and J ohn Janzen, eds. Berkeley: University of California Press. Abdulaziz, Mohamed (1995) Impact of Islam on the Development of Swahili Culture. In Islam in Kenya: Proceedings of the national seminar on contemporary Islam in Kenya. Mohamed Bakari and Yahya Saad, eds. ME WA Publications. Nairobi, Kenya. Aday, Lu Ann and Ronald Andersen (1975) Development of Indices of Access to Medical Care. Ann Arbor: Health Administration Press. Agadjanian, Victor (2001) Negotiating through Reproductive Change: Gendered Social Interactions and Fertility Regulation in Mozambique. Journa l of Southern African Studies 27(2): 291-309. Agresti, Alan and Barbara Finlay (1997) Statistical Methods for the Social Scie nces. Third edition. Upper Saddle River: Prentice Hall. Alexander, G.R. and D.A. Cornely (1987) Racial Disparities in Pre gnancy Outcomes: The Role of Prenatal Care Utilization and Maternal Risk Status. American J ournal of Preventative Medicine, 3(5): 25461. Allen, Denise Roth (2002) Managing Motherhood, Managing Risk: Fert ility and Danger in West Central Tanzania. Ann Arbor: The University of Michigan Press. Allison, Paul (1999) Logistic Regression: Using the SAS System. Theory and Application. SAS Institute Inc., North Carolina. Antoun, Richard (1968) On the Modesty of Women in Arab Muslim Villages: A Study in the Accommodation of Traditions. Ameri can Anthropologist, 70 (4): 671-97.

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159 Ataudo, E.S. (1985) Traditional Medicine and Biopsychosocial Fulfillment in African Health. Social Science and Medicine, 21(12): 1345-47. Ayiemba, E.H.O. and Florence Mogere (1999) Reproductive Mortality and its Significance to Health Planning in Kisii District, Kenya. MILA (NS) 4: 9-23. Barnes-Josiah, D, Cynthia Myntti and Antoine Augustin (1996) The “Three Delays” as a Framework for Ex amining Maternal Mortality in Haiti. Social Science and Medicine, 46(8): 981-993. Beck, Ann (1981) Medicine, Tradition and Development in Kenya and Tanzania. Massachussetts: Crossroads Press. Beckerleg, Susan (1992) Medical Pluralism and Islam in Swahili Communities in Kenya. Medical Anthropology Quarterly. 8(3): 219-313. Berg, F. J. (1968) The Swahili community of Mombasa, 15001900. Bernard, H.Russell (1989) Native Ethnography: A Mexican Indian Describes his Culture. Newbury Park: Sage Publications. Bernard, H. Russell (1989) In Handwerker’s : Women’s Power and Soci al Revolution: Fert ility Transition in the West Indies. Newbury Park: Sage Publications. Bernard, H.Russell (1996) Research Methods in Anthropology. Second Edition. Qualitative and Quantitative Approaches. Walnut Creek: Altamira Press Bernard, H.Russel (2002) Social Research Methods: Qualitative and Quantitative methods.Thousand Oaks: Sage Publications Berer, Marge (1999) Reducing Perinatal HIV Transmission in Developing Countries through Antenatal and Delivery care, and Breastfeeding: S upporting Infant Survival by Supporting Women’s Survival. Bulletin of the Wo rld Health Organization, 77 (11): 871-877.

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160 Blanc, Ann (2001) The Effects of Power in Sexual Relati onships on Sexual and Reproductive Health: An Examination of the Evidence. Stud ies in Family Planning 32(3): 189-213. Boerma, J.T and F.J. Bennett (2000) Health and Illness. In Kenya Co ast Handbook: Culture, Resources and Development in the East African Littor al. Jan Hoorweg, Dick Foeken and R.A. Obudho eds. New Brunswick: Transaction Publishers. Brabin, B.J. (1983) An Analysis of Malaria in Pregnancy in Africa. Bulletin of the World Health Organization, 61(6): 1005-16. Brown, Judith (1963) A Cross-cultural Study of Female Initia tion Rites. American Anthropology 65(4): 837-53. Bunting, Sheila and Regina Seaton (1996) Health Care Participation of Perinatal Women with HIV: What Helps and What Gets in the Way? Health Care for Women International, 20:563-578. Butlerys, Mark and Philipe Lepage (1998) Mother-to-Child Transmission of HIV. Cu rrent Opinion in Pediatrics, 10:143-150 Caplan, A.P. (1976) Boy’s Circumcision and Girls Puberty Rites among the Swahili of Mafia Island, Tanzania. Africa: Journal of the Intern ational African Institute 46(1): 21-33. Cartoux, M., Meda, N., Van de Perre, P., Newell, M.L., de Vincenzi, I., Dabis, F. and the Ghent International Working Group on Mother -to-Child Transmission of HIV. (1996) Acceptability of Voluntary HIV Test ing by Pregnant Women in Developing Countries: An International Survey. AIDS, 12:2489-2493. Celik, Yusuf and David Hotchkiss (2000) The Socio-economic Determinants of Matern al Health Care Utilization in Turkey. Social Science and Medicine, 50:1797-1806. Chalmers, Beverly, Mangiaterra, Viviana, and Richard Porter (2001) WHO Principals of Perinatal Care: The Essential Antenatal, Perinatal and Postpartum Care Course. Birth 28:3 Chami, F. (2002) Kaole and the Swahili World. In Southern Africa and the Swahili World. F. Chami and Gilbert Pwiti, eds. Dar es Salaam: University Press Limited.

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161 Chavez, L., Hubbell, A., McMullin, J., Martinez, R. and S. Mishra (1995) Structure and Meaning in Models of Breas t and Cervical Cancer Risk Fators: A Comparison of Perceptions among Lati nos, Anglo Women and Physicians. Medical Anthropology Quarterly, 9(1): 40-74. Chavunduka, G.L and Murray Last (1986) The Professionalization of Af rican Medicine. Manchester: Manchester University Press. Chrisman, N.J. and T.W. Maretzki (1982) Clinically Applied Anthropology: An thropologists in Health Science Settings.Hingham: Kluwer Boston. Colson, Anthony (1971) The Differential Use of Medical Resources in Developing Countries. Journal of Health and Social Behavior, 12(3): 226-237. Coreil, J., Barnes-Josiah, D., Augustin, A., and M. Cayemittes (1996) Arrested Pregnancy Syndrome in Haiti: Fi ndings from a National Survey.Medical Anthropology Quarterly, 10(3): 424-36. Crandon, Libbet (1986) Medical Dialogue and the Political Economy of Medical Pluralism: A Case from Rural Highland, Bolivia. Ameri can Ethnologist, 31(3): 463-76. Davidson, B (1991) African Civilization Revisited. Trenton: Africa World Press. DeBlij, Harm Jan (1968) Mombasa: An African City. Evanston: Northwestern University press. Dicko, A., Mantel, C., Thera, M., Doumbia, S. Diallo, M., Diakite, M., Sagara, I and D. Doumbo (2003) Risk Factors for Malaria Infection and An emia for Pregnant Women in the Sahel area of Bandiagara, Mali. Acta Tropica 89: 17-23. Dildy III, G., Martens, M., Fa ro, S. and Wesley Lee (1990) Typhoid Fever in Pregnancy: A Case Report. The Journal of Reproductive Medicine 35: 3. Echavarria, S. and F. Parker (2001) Race/Ethnic-Specific Variation in Adequ acy Care Utilization. Social Forces, 80 (2): 633-54.

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162 Fabrega, Horacio (1997) Evolution of Sickness and Health. Be rkeley: University of California Press. Fabrega, Horacio Jr. and R. Manning (1979) Illness Episodes, Illness Severity and Tr eatment Options in a Pluralistic Setting. Social Science and Medicine, 13B: 41-51. Feierman, Steven (1981) Therapy as a System-in-Action in Nort hern Tanzania. Social Science and Medicine, 15B: 353-360. Feieman, Steven and John Janzen, (eds.) (1992) The Social Basis of Health and Heali ng in Africa. Berkeley: University of California Press. Foster, George and Robert Kemper, (eds.) (1973) Anthropologists in Cities. Bost on: Little, Brown and Company. Frackenberg, Ronald and Joyce Leeson (1976) Disease, Illness and Sickness: Social Asp ects of the Choice of Healer in a Lusaka Suburb. In Social Anthropology and Medicine. J.B. Loudon, ed. Pp.223-258. London: NewYork Academic Press. Freeman-Greenville, G.S.P. (1980) Mombasa Martyrs of 1631. London: Oxford University Press. Gaillard, P., Verhofstede, C., Mwanyumba, F., Claeys, P., Chohan, V., Mandaliya, K., Bwayo J., Plum, J and M. Temmerman (2000) Vaginal Lavage with Chlorhexidine Du ring Labor to Reduce Mother-to-Child HIV Transmission: Clinical Trial in Mombasa, Kenya. Gardner, Michael, Susan Cliver, Sandre McNeal and Robert Goldenberg (1996) Ethnicity and Sources of Prenatal Care: Findings from a National Survey. Birth, 23(2): 84-87. Golomb, L. (1988) The Interplay of Traditional Therapies in South Thailand. Social Science and Medicine, 27(8): 761-8. Good, Byron (1986) Explanatory Models and Care-Seeking: A Critical Account. In Illness Behavior: A Multidisciplinary Model. S. McHugh and T.M. Vallis, eds. Pp. 161-172. New York: Plenum Press.

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163 Goodburn, E., Gazi, R. and M. Chowdhury (1995) Beliefs and Practices regarding Delivery and Postpartum and Maternal Morbidity in Rural Bangladesh. Studies in Family Planning, 26(1): 22-32. Grjibovski, A., Bygren, L., and B. Svartbo (2002) Socio-demographic Determinants of Poor Infants Outcome in North-west Russia. Paediatric and Perinata l Epidemiology, 16: 255-62. Gruenbaum, Ellen (1996) The Cultural Debate over Female Circum cision: The Sudanese arguing this One out Themselves. Medical Anthr opology Quarterly 10(4): 455-75. Guay, L., Musoke, P., Thomas, F., Bagenda, D., Allen, M., Nakabiito, C., Sherman, J., Bakaki, P., Ducar, C., De seyve, M., et al. (1999) Intrapartum and Neonatal Si ngle-dose Nevirapine Compar ed with Zidovudine for Prevention of Mother-to-Child Transmi ssion of HIV-1 in Kampala, Uganda: HIVNET 012 Randomised Trial. The Lancet, 354: 795-802. Gupta, S., Verhoeven, M. and E. Tiongson (2003) Public Spending on Health Care and the Poor. Health Economics, 12: 685-96. Guyatt, H.L., Noor, A., Ochola, S., and R.W. Snow (2002) Use of Intermittent Presumptive Treatment and Insecticide Treated Bed Nets by Pregnant Women in Four Kenyan District s. Tropical Medicine and International Health 9(2): 255-261. Guyatt, Helen L. and Robert W. Snow (2004) Impact of Malaria during Pregnancy on Lo w-Birth Weight in Sub-Saharan Africa. Clinical Microbiology Reviews 17(4): 760-69. Handler, Arden, Kristiana Raube, Michel e Kelley and Aida Giachello (1996) Women’s Satisfaction with Prenatal Ca re Settings: A Focus Group Study. Birth, 23:1 Handwerker, W. Penn (1989) Politics of Reproduction: A Window on So cial Change. In Birth and Power: Social Change and the Politics of Re production. Boulder: Westview Press. Handwerker, W. Penn (1989) Women’s Power and Social Revolution: Fertility Transition in the West Indies. Newbury Park: Sage Publications Handwerker, W. Penn (2001) Quick Ethnography. Walnut Creek: Altamira Press.

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175 BIOGRAPHICAL SKETCH Fatima Soud was born in Mombasa, Kenya, where she lived most of her life. She moved to Nairobi where she started her nur sing career at the Nairobi Hospital. On completion, she attended the Mater Misericord iae Hospital where she did her midwifery training. She is also registered as a nurse with England and Wales. She practiced as a nurse in Gainesville, Florida, wh ile pursuing her doctorate degree. In 1983, Soud worked with DeRance (Cat holic) Foundation out of Milwaukee, Wisconsin. With this organization she traveled back to East and Central African countries where she assessed allocation and expenditure of grants and funds. These funds were given to build health rela ted development projects. In 1994-95 and 2002-03, Soud taught as a Swahil i instructor at the University of Florida in the Department of African and Asian Languages and Literature. In the summer of 2004, Soud did an internsh ip at the Methods Research Section (Prevention Research Branch) in the Division of HIV/AIDS Preventi on, at the Center for Disease Control and Prevention (CDC). She assi sted in two studies; (a) an evaluation of the implementation of an evidence-based CDC behavioral intervention for HIV prevention program with the Texas Department of Health, and (b) a study of the current HIV transmission among men who have sex with men (MSM) in King County, Seattle. Soud will begin a two-year on the job training as an Epid emic Intelligence Service officer with the CDC in Atla nta, Georgia, in July 2005.


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Material Information

Title: Medical Pluralism and Utilization of Maternity Health Care by Muslim Women in Mombasa, Kenya
Physical Description: Mixed Material
Copyright Date: 2008

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Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
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MEDICAL PLURALISM AND UTILIZATION OF MATERNITY HEALTH CARE
SERVICES BY MUSLIM WOMEN INT MOMBASA, KENYA















By

FATMA ALI SOUD


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2005

































Copyright 2005

by

Fatma Ali Soud


































This document is dedicated to my parents.
















ACKNOWLEDGMENTS

This research would not have been possible without the help of many people. I

would like to thank Dr. Abdalla Kibwana who was my first listener and consultant while

writing the proposal and questioning the feasibility of this study.

I owe a huge debt to the 300 women I interviewed and to the many others who took

time to answer my questions. I was invited into women's lives and entrusted with very

personal and intimate information. I owe great gratitude to Sister Asya Ahmed who

opened her home and birthing center and gave me a lot of her time to explain all the

social and cultural changes that had taken place in Mombasa. In addition, she took time

to re-introduce me to the many physicians, nurses (especially Sister Rumani Ahmed and

Mura Thabit), to the birth attendants Bi Riziki, and Amina AbdulGhania. To Dr.

Khadij a Shikeli for allowing me entrance into Coast General Hospital. To all the

administrative staff and nurses of MEWA, Sayyida Fatima and Al-Farouk hospitals who

took time to answer my questions.

My sincerest gratitude to Dr. Russell Bernard for his faith in me, his critical

counsel in research design, methods, editing and advice. I feel honored to have grown

academically under his tutelage. A very special acknowledgement to my committee

members, Drs. James Stansbury, Elizabeth Guillette, and Jeffrey Harman. Thank you for

your intellectual inspiration and professionalism. I had the privilege of guidance from

other professors who I would like to thank, Drs. Brian du Toit, Michael Chege, Leslie

Sue Lieberman, Sharleen Simpson and Maria Grosz-Ngate.










To my fellow student supporters, particularly the dissertation writing group, Roos

Willems, Antoinette Jackson, Elli Sugita and Alex Rodlach, thank you for tirelessly

reading, editing and providing input as the dissertation progressed. Special thanks to Alex

for his friendship, support and encouragement, and for listening as the dissertation took

many forms until it was written.

Deepest appreciation to my family in Mombasa, Faiza and Abdul Abdulbassit and

Aisha who invited my sons and me to live with them during fieldwork. To my sisters

Sabrina, Umi and Nasra for their love and encouragement. Last but not least to my sons,

Abraham and Adam Wilcox for their love and support and their ability to keep me

grounded.





















TABLE OF CONTENTS


page

ACKNOWLEDGMENT S .............. .................... iv


LI ST OF T ABLE S ............ ......_ .............. ix...


LIST OF FIGURES .............. ...............x.....


ACRONYM S ................. ................. xi..............


GLO SS ARY .............. .................... xii


AB STRAC T ......__................ ........_._ ........xi


CHAPTER


1 LITERATURE REVIEW ................. ...............1...............


Introducti on ................. ...............1...._.._ ......
Theoretical Overview .................. ... ........... .... ...........6
Theoretical Models in Health Care Seeking Behavior............_..._ ............... ....6
Mother-to-chil d-tran smi ssi on (MT CT) of HIV ........................_. ............... 8
Prenatal care services ................. ........._. ... ...............10.....
What is adequate utilization of prenatal care? ................. ........._.._.......1 1
Utilization and access of prenatal care services .........._.._.._ .............. .....12
HIV positive women and the utilization of health care .........._..... ..............15

2 MOMBASA THE RESEARCH AREA .....__.....___ ........... ............1


Geography .............. .. ..... ._ ..... ...............18_
History: The Visitors and Administrators. .....__.....___ .......... .............1
The Coastal People Waswahili.............__ ...... ..__ .........__ ...........2
What Occupies Women's Time in Mombasa? Society and Culture ................24

3 MEDICAL PLURALISM INT MOMBASA. .......___......... .........___......30


Introducti on ............ _. .... ...............30....
Biomedical Health Care............... ...............3 1.
Traditional/ Folk Medicine ........._.. ...._._........._._. ............3












Islamic Heal ers .............. ...............40....
The Popular/ Lay Sector ................. ...............43........ .....


4 METHODS OF DATA COLLECTION................. .............4


Introducti on ................... .. ...... ...............45.....
Research Design and Obj ectives ................. ......... ...............45.....
Native Ethnography ................. ...............47....... ......
Sampling Design .............. ...............50....
Data Collection ................. ...............52....... ......
The Research sites ...._. ................. ...............57......
Statistical methods............... ...............66


5 RESULTS FROM THE DATA ANALYSIS .............. ...............67....


Introducti on ................. ...............67._ _._.......

A analysis .............. .......... ... .. .........6
Section A Socio Demographic Characteristics............... ............6
Section B Household Characteristics ........................................... 7
Section C Knowledge of Mother-to-Child HIV Transmission (MTCT)..........77
Obstetrical Characteristics.................... .................7
Section D Utilization of Maternity Health Care Services ............... ............._...80
Choice of a childbirth delivery center ................. ................. ................. .81
Reasons for using a facility for prenatal care or childbirth ................... .......82


6 ETHNOGRAPHY OF PREGNANCY AND CHILDBIRTH ................. ................87


Introducti on ................ ..... ...... .... ........... ... .... .... .. ... .......8
Menstruation and Puberty Rites Lessons On How to Safeguard Fertility ..............87
Infertility ........._. ...... .. ...............9 1....
Pregnancy Loss ........._... ...... ..... ...............95....
Perceptions of pregnancy ......_.. ............_ ........._.._......_._....96
Prohibitions in pregnancy............... ...............9
Illnesses in Pregnancy .............. ...............100....
Childbirth ................. .... .. ..............10

Postpartum period (Arubaini) ....._._._ ...... ._.. ....._. ...........13

7 SUMMARY AND CONCLUSION ............_. ....._. ....__ ...........18


Introducti on .........._........ ......_._. .. ._._ ........... ......... 1

Demographic and Obstetrical Determinants of Health Care.........._.._.._ ...............1 19
Household Characteristics and the Domestic Economy ................. ........._......123
Local and State Political Economy and Health Care............... .................12
Culture and Women's Health Beliefs............... ...............126











APPENDIX

A DEMOGRAPHIC CHARAC TERI STIC S ...._ ................. .........__.. .....12


B QUESTIONNAIRE ................. ...............145...__ ........

C CODING FOR QUESTIONNAIRE ...._. ................. ............... 149 ....

LIST OF REFERENCES .........._.. ........... ...............158...

BIOGRAPHICAL SKETCH .............. ...............175...__.........

























































V111


















LIST OF TABLES

Table pg

4-1 Interview sites .............. ...............52....

A-1 Section A Demographic characteristics ................ ...............136..............

A-2 Section B Household characteristics............... ............13

A-3 Section C Knowledge of mother-to-child- HIV transmission ................... ..........140

A-4 Use of maternity health care. ................ ............ ......... ........ .........141

A-5 Logistic regression model results of the determinants of using prenatal care ....143

A-6 Logistic regression model odds of choosing of a birthing facility as reported
by respondents ....._ ................. ........_ ..........14

E-1 Coding for Questionnaire ................ ...............149...............


















LIST OF FIGURES


figure pg

2-1 Map of Kenya situating Mombasa ..........._... ...___....... ..........1

4-1 Data collection sites .............. ...............51....

A-1 Percentage of respondents by ethnicity ........__............._. ............... 129 ...

A-2 Respondents' level of secular education .....___ ................ ........_.._. ......13

A-3 Respondents' knowledge about mother-to-child HIV transmission ......................131

A-5 Month biomedical prenatal care started .............. ...............133....

A-6 Respondents' number and frequency of prenatal care visits .........._.... ..............134

A-7 Percentage of respondents choice of birthing facilities .........._. ... ......_._. .....13 5
















ACRONYMS

AIDS Acquired immuno-deficiency syndrome

HIV Human immunodeficiency virus

MCH Maternal child health

MOH Ministry of Health

MTCT Mother-to-child transmission

NGO Non-government organization

TBA Traditional birth attendant

STI Sexual transmitted infections

UNAIDS United Nations AIDS organization

UNFPA United Nations Population Fund

UNICEF United Nations Children's Fund

WHO World Health Organization
















GLOSSARY

Swahili Culture of the people of East African coast from Mogadishu (Somalia) to
Southern Mozambique.

Mswahili The person (plural Waswahili or the people)

Kiswahili Language used by the Waswahili

Kenya shilling (Ksh.) Money used in Kenya the exchange rate was Ksh. 75-80 to the
dollar. Minimal wage ranged between Ksh. 8,000 to 20, 000.

Kanga/ Leso A rectangular piece of colorful cotton cloth, approximately three by one
feet with multi-purpose use, worn in pairs.
















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

MEDICAL PLURALISM AND UTRLIZATION OF MATERNITY
HEALTH CARE SERVICES BY MUSLIM WOMEN INT MOMBASA, KENYA


By

Fatma Ali Soud

May 2005

Chair: H. Russell Bernard
Major Department: Anthropology

This is a study of health-seeking behavior of pregnant Muslim women in

Mombasa, Kenya. Early initiation and attendance of prenatal care has been shown to

result in positive pregnancy outcomes. In addition, birth delivery assistance from a

trained and well-equipped provider is necessary to reduce maternal morbidity and

mortality.

Kenya, among other countries in Africa has a high maternal mortality rate. The

maj or direct causes of mortality are hemorrhage, sepsis and hypertensive diseases of

pregnancy. Malaria, anemia, tuberculosis and HIV/AIDS as well weaken the immune

system and add to the toll of death during childbirth. Due to the HIV/AIDS epidemic,

Mombasa has an increasing rate of mother-to-child transmission (MTCT). In this study,

women' s knowledge of MTCT is assessed.

To address these above issues, Kenya developed a Safe Motherhood Initiative in

1987. This initiative was to identify poverty reduction strategies among women, improve










reproductive health and assure child survival. The research reported here adds to the

studies of the Safe Motherhood Initiative from the women' s perspective. I believe that

many of the findings of the research reported here can apply to urban areas across Kenya

and, indeed elsewhere in urban Africa where medical pluralism is the norm.

I investigated the available maternal health care services and how, when and why

women used or did not use them. I used participant observation followed by and a

questionnaire to collect data from 265 Muslim women. Logistic regression techniques

are used to estimate models of prenatal care use and choice of a birthing facility. Women

were interviewed during the postpartum period, while in the hospital, at home and while

attending the sixth week check-up. The results demonstrate the complexities of women' s

lives and the difficulties they face in accessing maternity health care. Their reasons for

not getting the care they need include cost, distance, lack of competence of health care

providers, and frequent shortages of essential equipment and supplies to provide basic

essential obstetrical care. In addition, their beliefs, knowledge and attitudes about the

efficacy of health care services and the curability of their condition affect their health-

seeking behavior.















CHAPTER 1
LITERATURE REVIEW

Introduction

This is a study of health-seeking behavior of pregnant Muslim women in Mombasa,

Kenya. Mombasa has an increasing rate of mother-to-child HIV transmission and a high

maternal morbidity and mortality. HIV-positive women transmit the virus to their infants

during pregnancy, during childbirth and while breastfeeding. HIV positive children fail to

thrive and have delayed motor development, with deceleration in mental health. These

children have a poor prognosis. Their health deteriorates at a faster rate due to AIDS, and

mortality is hardly past five years of age (Butlerys and Lepage 1998). In 2001 Kenya had

220,000 cases of pediatric HIV infection from mother-to-child transmission

(UNAIDS/WHO Epidemiological Fact Sheets 2002).

Kenya has a high maternal mortality. In 2001 it was estimated at 590 deaths per

100,000 births, and this is likely to be an underestimate since many maternal deaths are

not reported. The director of medical services in Kenya estimates that from 3300 to 6000

Kenyan women die each year of pregnancy related causes (Ministry of Health 1997). The

maj or direct causes of mortality are hemorrhage, sepsis, and hypertensive diseases of

pregnancy. Malaria, anemia, tuberculosis and HIV/AIDS weaken the immune system and

add to the toll of death during childbirth. To address these problems, Kenya developed a

Safe Motherhood Initiative in 1987. This initiative was to identify poverty reduction

strategies among women, improve reproductive health and assure child survival. The

Safe Motherhood Initiative was followed by a National Reproductive Health Strategy









covering the period 1997-2010. The strategy required all districts and provinces to a:

the causes of maternal and perinatal morbidity and mortality (Republic of Kenya 2001).

Pilot studies have been conducted across Kenya to assess the results of these safe

motherhood programs (Trangsrud and Thairu 1998). Findings reported here adds to these

studies of the Safe Motherhood Initiative. I believe that many of the findings of the

research reported here apply to urban areas across Kenya and, indeed, elsewhere in urban

Africa where medical pluralism is the norm.

This study was initially set to interview HIV-positive women, however when I

arrived in Mombasa, I was informed by clinicians that this would be difficult since most

of the women are not tested, and if tested women do not return for results. Previous

studies explain that women do not return for results due to fear of knowledge of an HIV

positive status. Another obstacle was women who knew that they were HIV-positive did

not want to reveal their status due to stigma. Although I questioned if a respondent was

tested for HIV, I did not inquire whether one is positive or negative. Knowledge of

testing and counseling for HIV is an important component in maternity health care

assessment. I re-formulated the hypotheses as follows:

1. Muslim women who have strong Muslim beliefs will go to Islamic institutions

and healers compared to women without similar beliefs;

2. Women who have knowledge about MTCT will seek more adequate maternity

health care than will women without similar knowledge;

3. Women who develop pregnancy related illnesses or complications will seek

Islamic healers compared to women without complications.









To explore these above issues, I investigated the available maternal health care

services and how, when and why women used or did not use them. I used participant

observation followed by a questionnaire to collect data from 265 Muslim women in

Mombasa, Kenya. Prenatal care services and parturition in a well-run biomedical

facility would improve maternal and child health. However, although most women do not

deliver at home, the facilities that they do use do not provide the kind of care that can

reduce mother-to-child transmission of HIV.

The results demonstrate the complexities of women' s lives and the difficulties they

face in accessing maternity health care. In relation to the hypotheses, women who had

economic means independent of their spouses or family had better access to health care

than women who did not irrespective of religious beliefs or educational status. Women

whose economic status was dependent on spouses, partners, and family members had

varied reasons for lack of or poor access to adequate maternity health care. Their reasons

for not getting the care they need include cost, distance, lack of competence of health

care providers, frequent shortages of essential equipment and supplies to provide basic

essential obstetrical care. In addition, their beliefs, knowledge and attitudes about the

efficacy of health care services and the curability of their condition affect their help-

seeking behavior.

In this chapter, I explain the different theoretical models used by medical

anthropologists in analyzing non-Western health care decision-making processes and

behavior. Kleinman's (1978, 1980) explanatory model is appropriate for this study, it

incorporates the individual's cultural response to illness and treatment. Furthermore, the

model refers to the patient' s and family's conceptions of the nature of a particular illness










episode, its causes and effects, expected and /or desired treatment and apprehensions

about the outcome .

In this chapter, I also explain the three routes through which a mother can transmit

HIV to her infant, and the preventive and curative methods to decrease or avoid

transmission. I also discuss the importance of prenatal care to illustrate what women

should be receiving when they get efficient care. From my personal experience as an

obstetric nurse, the expectations developed in the United States about what constitutes

adequate prenatal care are unrealistic for Mombasa. I present below some of the debate

on the adequate number of prenatal care visits. I also review the literature on the use of

prenatal care services by women with and without HIV infection and compare it with the

results from Mombasa.

Chapter 2 outlines the geography and history of Mombasa and offers a brief

overview of Muslim women' s life there. Mombasa has 750 years of recorded history and

it is unique on the African continent. The town's cultural and ethnic mixture comprises

the local Bantu with Arab, Indian, Portuguese, Chinese and British soj ourners, some of

whom remained in Mombasa to this day. "If a society or culture does not develop

procedures for healing and curing, it does not exist," says Rush (1996: 13 8) and indeed,

Mombasa' s fluid and plural medical system, developed from its turbulent history, as I

explain in Chapter 3.

Chapter 3 outlines the medical pluralism practiced in Mombasa. Kleinman's (1978,

1980) explanatory model divides medical pluralism into three sections: biomedicine,

traditional medicine, and the lay sector. Islamic health practices are found in all three

sectors. In Mombasa, biomedicine is respected by Muslims when treatment is required









for outbreaks of diseases such as typhoid. However, when the agent for an illness is

suspected to be supernatural, Muslims in Mombasa seek other means of healing. In this

way, they are similar to Christian Indians in Latin America (Crandon, 1986), Hindus in

India (Subedi 1989) and Buddhists in Thailand (Golomb 1988, Techastraisak and Gesler

1989). The dissatisfaction of one therapeutic system to heal or cure leads users to try

others until a remedy is achieved.

Chapter 4 explains the methods used in this research. I present the research design

and obj ectives, the advantage and disadvantages of native ethnography. In addition, I

illustrate the areas and methods of data collection and the sampling design.

Chapter 5 presents the major results from analysis of the 265 questionnaires. The

individual respondent's questionnaires provided information on the following:

demography, household characteristics, knowledge of mother-to-child HIV transmission

and use of maternity health care services. Logistic regression models the use of various

prenatal and natal health care options

The ethnography of pregnancy, childbirth and postpartum is presented in chapter 6.

I have included women's concerns of secondary infertility and pregnancy loss and the

herbal and ritual prohibitions and treatment to ensure fertility. Furthermore, I incorporate

illnesses that women perceive as risks for a pregnancy and the plural methods used to

treat these conditions. I finally narrate my experience of observing childbirth in a home-

birthing center.

In Chapter 7, I present the summary and conclusion using cultural materialism as a

theoretical tool to evaluate the different components that impede or assist women's

access to maternity health care. I divide these varied factors into the format of









infrastructure (demography, occupation, and obstetrical characteristics), structure

(education, domestic and political economy) and superstructure (values and beliefs). This

model takes into account that there is a relationship between all of these above elements

when women seek health care. The concept of reproductive health is a basic human right

and any of the above factors can help or infringe on this right.

Theoretical Overview

Theoretical Models in Health Care Seeking Behavior

Medical anthropologists have offered five different frameworks for analyzing

decision-making about health care in non-Western societies. These are the determinant,

process, mental, systems and critical models. Although these models may provide

"overlapping, sometimes contradictory explanations of similar phenomena," (Ryan

1995:7) no single framework appears adequate for explaining a group's health-seeking

behavior.

The determinant model attempts to account for intra- and intercultural variation in

health-seeking behaviors by examining the characteristics of illnesses, patients,

caretakers, households, communities and health care services, as well as the individual's

actions and willingness to seek care (Mechanic 1969, Colson 1971, McKinley 1973,

Foster and Kemper 1973, Fabrega and Manning 1979 and Stoekle et al. 1963). Friedson

(1960), Suchman (1964), Chrisman and Maretzki (1982), Igun (1979), and Young (1981)

emphasize that decision making about health care is a process rather than simply a

determined outcome. The process begins with awareness of an illness, followed by

diagnosis, selection among alternative therapies, and evaluation of the therapy. This can

lead to new choices and re-evaluation of outcomes. Nyamongo (1998) and Mbeh (2000)









found the process model to have more predictive power in assessing response to infant

diarrhea and malaria respectively.

Frackenberg and Leeson (1976), Feierman (1981), and Young (1981) describe the

systems model as the impact of social forces on the search for health care. This model

according to Janzen (1978) requires two levels of analysis, one at the micro level

(incorporating perceptions about an illness, the prevalence of the illness, and efforts to

diagnose, prevent, and cure an illness) and one at the macro level (incorporating

information about large scale social entities such as health institutions, economic and

political systems that dictate access to health care. Janzen (1978) points out that, in most

non-Western societies, the reaction to illness involves a "therapy management group"

comprising the friends, family and others in the social network of the ailing individual.

McKinlay (1973:275) adds that "the family, its kinship and friendship networks,

influence the manner in which individuals define and act (or fail to act) upon symptoms

of life crisis."

Kleinman (1978, 1980), Cominsky (1982), MacCormack (1982) and Good (1986)

formulated the mental models approach to health care seeking. This model focuses on

how people understand and experience their illness and that of others around them. This

understanding is, of course, a function of local culture. Kleinman's (1978:86) proposes a

theory using the explanatory model (EM) to describe illnesses in different sectors of the

health system. For each illness, according to the EM approach, there is a set of beliefs

about its etiology, onset of symptoms, pathophysiology, development, severity, and

treatment, as well as about appropriate roles for those afflicted. In addition, the EM

approach examines macro-level or external factors, such as the political, economic,









social, historical and environmental determinants in health care seeking behavior. Singer

(1990) has criticized Kleinman' s use of the EM approach and ignoring power relations

between social groups and between classes. I take this critique into consideration in

analyzing the data reported here. The EM approach, in theory, provides a way to make

cross-cultural comparisons of health-seeking behavior. Unfortunately, while many

scholars have done EM studies, systematic comparison for commonalities across cultures

has not yet been achieved. Indeed, I offer the research reported here as a contribution to

EM research, but leave for later the systematic comparison of models for seeking prenatal

and perinatal care.

The critical approach in medical anthropology focuses on how "political and

economic forces, including the exercise of power are used in shaping health, disease,

illness experience and health care" (Singer and Baer 1995:5). This model is "holistic,

historical and immediately concerned with on-the-ground features of social life, social

relations and social knowledge, as well as with culturally constituted systems of

meaning" ibidd: 81; see also Morgan 1987, Singer 1986, 1990, Singer et al. 1992). The

critical model focuses explicitly on macro-level forces to explain behavior rather than on

the individual, though the ethnographic data on which critical analyses are based are

often individual-level narratives (Scheper-Hughes 1992).

Mother-to-child-transmission (MTCT) of HIV

MTCT of HIV-1 can occur before, during or after birth. The contribution of each of

these routes has not been well identified, but it is estimated that two- thirds of potential

exposure occurs in utero and during birth while one-third occurs post-natally.

Understanding the risk of infection from these different routes has been important in

public health for the development of appropriate interventions. According to Newell










(1998), HIV can infect the placenta at all stages of pregnancy, and infected placental cells

may be passed to the fetus during childbirth. She concurs that when the amniotic sac is

intact, transmission may occur from the placenta to the fetus in fetoplacental circulation.

Studies to support intrauterine transmission have detected the "virus from fetal material

as early as 12 weeks' gestation, the intrauterine onset of symptomatic HIV disease, and

the identification of HIV in amniotic fluid" (Newell 1998:83 1). Infants have tested HIV

positive within days of birth, with some infections progressing rapidly, suggesting

intrauterine transmission ibidd).

HIV transmission during labor and delivery occurs in two ways. One is from direct

contact of the infant with infectious maternal blood and genital secretions during passage

through the birth canal. The other is through ascending infections from the vagina or

cervix to the fetal membranes and amniotic fluid through absorption in the infant' s

digestive tract. In either case, cesarean section is appropriate for prevention, with

immediate suctioning of oral and nasal secretions of the infant. The presence of HIV has

been identified in the birth canal, with higher levels in pregnant than in non-pregnant

women. Trials to assess reduction during delivery by antiseptic cleansing of the birth

canal have been conducted in Malawi (Biggar et al. 1996), but results showed no

significant impact on HIV transmission rates, except when membranes were ruptured for

more than four hours before delivery. Studies also suggest a reduction in the rate of

MTCT with the use of zidovudine (AZT) in pregnancy and at the time of delivery, though

the drug has little effect on the serostatus of the mother. AZT during pregnancy and

delivery has become the standard treatment in developed countries, producing a

transmission rate of fewer than 8% in regimen-compliant women. This is still not an










option in most of sub-Saharan Africa because of the cost of AZT and other

antiretrovirals. A single dose of nevirapine, however, given to the mother before she goes

into labor, and a single dose given to the baby within 72 hours of birth, has proven a cost

effective treatment to reduce MTCT in developing countries (Stringer et al. 2000), with

trials in Uganda (Guay et al. 1999) and in Zambia (Marseille et al. 1998). Other studies

done to improve care during delivery (Taha et al. 1997 and Gaillard et al. 2000) have

examined possible interventions to reduce MTCT by antiseptic cleansing of the birth

canal before parturition.

In the postnatal period, breastfeeding has been associated with increased MTCT.

The rates are higher in women who are newly infected compared to women with stable

infection. Present studies are not clear concerning the possibility of increased HIV in

colostrum. Mixed feeding practices also increases risk of infection, due to damage of the

infant' s intestinal tract from the early introduction of other foods. Some infants who

initially test negative at birth become infected at 3-6 months, and in the developed

countries, women on postnatal HIV therapy are discouraged from breastfeeding

(UNAIDS 1998).

Most studies done in Kenya have concentrated on voluntary counseling and testing

for HIV (Cartoux et al. 1996, Vollmer et al. 1999 and Sweat et al. 2000) specifically to

evaluate the acceptability and cost of testing.

Prenatal care services

The proper use of prenatal care services results in positive pregnancy outcomes by

reducing the risk of maternal and infant morbidity and mortality. Health care centers

offering prenatal care provide an informal risk assessment based on clinical judgment to










guide the providers appropriate monitoring and possible interventions during the

pregnancy (Aday and Andersen (1975).

Various factors ((previous medical and obstetrical history, screening laboratory

results, and intrapartum events that predict perinatal morbidity and mortality) are

assigned risk scores which, together, produce a probability of premature or low-birth

weight delivery. Prenatal risk assessment also assesses the probability of adverse

perinatal outcomes (Murata et al. 1992).

Prenatal evaluation continues with urine analysis and blood tests for rubella,

hepatitis B, gonorrhea, chlamydia, genital herpes simplex and HIV. Where available,

screening for congenital fetal disorders, like Down's syndrome, neural tube defects and

Rhesus isoimmunization are performed (Oldenetti et al 1996). Screening for anemia is

important in Mombassa because of the high prevalence of malaria and sickle cell anemia.

The diagnosis of common pregnancy complications, such as intrauterine growth

restriction, post-term pregnancies, pregnancy induced hypertension and gestational

diabetes, is necessary to prevent adverse outcomes. Reassessment of the mother' s well-

being continues throughout pregnancy along with education on the physical and

emotional changes associated with pregnancy. Women who follow through with prenatal

care also get information about childbirth, breastfeeding, and infant care classes. Despite

the measurable benefits of prenatal care, women in developing countries do not

adequately use the services (Berer 1999).

What is adequate utilization of prenatal care?

How much prenatal care is enough? With all the research, this is still a

controversial question. In Switzerland and Singapore (Sen et al. 1991), just three prenatal

care visits are considered adequate, while in the United States, 9-12 visits are










recommended (Kessner 1973, Kotelchuk 1994, Standards for American College of

Obstetricians and Gynecologists 1985). For over three decades, the Kessner Index

(Kessner 1973) has prescribed nine prenatal care visits for a normal pregnancy.

Kotelchuk (1994) Alexander and Cornely (1987) argue that the number of visits is less

important than the content and timing of visits. Adding to the confusion, Mahan (1996)

asserts that indices for judging the adequacy of prenatal care are not useful at all.

"Quality of prenatal care," he says "needs to be judged at the local level. Outcomes of life

or death or handicap are the ultimate measures of quality care" (1996:418).

The World Health Organization advocates, that maternity care should be a

"multidisciplinary, holistic, demedicalized, yet evidence-based approach that involves

women, and their families in decisions about their care" (Chalmers et al. 2001).

Fortunately, empirical evidence is available on this problem. Munjanja et al. (1996)

compared women in Harare, Zimbabwe, who had 12-14 visits with women who had six

visits. Among the 16,000 participants in this randomized field study, there were no

significant differences in pregnancy outcomes, at the aggregate level, for women in the

two experimental conditions. Based on this finding, I consider six visits as adequate

prenatal care.

Utilization and access of prenatal care services

In 1998, a joint UNAIDS/UNICEF/WHO working group announced an initiative to

reduce perinatal transmission of HIV. The intervention was formulated to increase infant

survival, based on a package of six components:

-Early access to adequate prenatal care,

-Voluntary and confidential counseling and HIV testing for women and their
partners,











-A short course of perinatal antiretroviral treatment for HIV positive women
before delivery and the newborn at birth,

-Improved care during delivery,

-Counseling and support for safe infant feeding practices (Berer M 1999:872).


Many studies show that cultural, structural, and infrastructural barriers to prenatal

care all play a role in determining the rate of adverse outcomes of pregnancy. (See

Mabina et al. 1997, Lang and Elkin 1997, Goodburn et al. 1995, Campbell and Kelly

1995, Wall 1998, McCray 1982 and see Paredes et al. 2005, Romoren et al. 2005,

Manadhar et al. 2004, Nigenda et al. 2003, for recent examples. See Medley et al. 2004

for a review.)

The study I report here focuses on Muslim women's access to prenatal care and

their actual health-seeking behaviors in Mombasa. Pregnant women cannot get HIV

testing and counseling unless they go to a prenatal care health center that provides these

services. A positive HIV test is the entrance for perinatal intervention to decrease MTCT.

The challenge that health care providers and researchers face has been to understand

women' s rationale for not using preventative services even when they are aware of the

benefits .

It is not necessarily the cost of services that prevents women from fully using

prenatal services, but living a "crisis existence and dealing with issues of financial

difficulties" (McKinlay and McKinlay 1972:377; and see Celik and Hotchkiss 2000,

Jelley and Madeley 1983, McKinlay and McKinlay 1972, Sargent and Rawlings 1991,

and Wilkinson et al. 2001). For example, user fees for preventative primary health care

were removed in South Africa in 1994 but this did not improve prenatal care utilization










(Wilkinson et al. 2001). By contrast, low-income HIV- positive African-American

women on Medicaid in New York improved their use of prenatal care (with concomitant

improvement in birth outcomes), once a program was implemented to enhance the

women's understanding of health-seeking behaviors (Turner et al. 2000).

Studies of African-American, Mexican-American and Puerto-Rican women in the

United States indicate an association of low socioeconomic status (SES) and

marginalization with low-birth weights, premature deliveries and adverse pregnancy

outcomes (Echavarria and Parker 2001, Gardner et al. 1996, Lia-Hoagberg et al. 1990,

Petitti et al. 1990, Turner et al. 2000). In Britain, Petrou and colleagues (2001) infer that

women of Pakistani and Indian origin made fewer prenatal care visits than attendance

made by white British women, possibly due to cultural and religious beliefs. Magadi et

al. (2000) in their study of frequency and timing of prenatal care in Kenya state that

women' s attendance was inconsistent, suggesting further research of traditional beliefs,

religious and cultural practices.

Other demographic factors included in most of the above studies included age,

parity, obstetrical histories and desire for the pregnancy. Teenagers and uneducated

women under-utilize prenatal care services (McCaw-Binns et al. 1995). There is also

documentation that prior adverse obstetric experience is a barrier to seeking early care

(Ivanov and Flynn 1999).

Lack of support from family and friends, particularly to assist with childcare or

transportation, is a structural barrier to the use of prenatal care (Winston and Oths 2000).

In some societies, women have to ask for permission from their partner, their in-laws or

their co-wife before leaving the household. The permission giver must therefore be an









advocate of biomedical health care. In Mombasa, the saying that "pregnancy is not an

illness" implies that women should not use the need for prenatal care as an excuse for not

fulfilling their familial and social obligations during pregnancy. The saying is clearly a

cultural artifact, but it belies a structural barrier, because so much of daily life (cooking,

cleaning, and taking care of infants, taking care of sick and frail relatives and friends)

depends on women's remaining active during pregnancy.

In terms of infrastructure, the sheer presence of low-cost, easy-to-reach clinics can

have an impact on the rate of use of prenatal care. Women often say that they are put off

by the long lines at clinics, inconsistent health care providers, the lack of female staff,

and a general lack of confidence with the health care system (Barnes-Josiah et al. 1996,

Handler et al. 1996, Ivanov and Flynn 1999, Mayer 1997, Petrou et al. 2001) Despite the

importance of these factors, all the evaluation studies just cited agree that strong rapport

between the pregnant woman and her health care provider increases women's health

attendance.

HIV positive women and the utilization of health care

Good communication between health care providers and pregnant women with

HIV is all the more important because these women deal with the challenges of taking

care of themselves, their families and their children in an environment of fear, guilt,

"stigma, uncertainty, and limited access to information and health care" (Bunting and

Seaton 1996:563). Lack of privacy is a maj or satisfaction issue in health care centers in

Mombasa due to overcrowding. In order to create privacy, counseling rooms for HIV

positive women have been made available in a few facilities through Horizons Project of

the Population Council a USAID venture (USAID 2001). Unfortunately, unlike other

pregnant women, HIV positive pregnant women have an added concern while attending










prenatal care clinics the fear of disclosure of their HIV status to a spouse or boyfriend,

family member, neighbor or co-worker (Sobo 1995).

Walter et al. (2001) found that, though new mothers were not knowledgeable about

perinatal HIV transmission and did not trust health care institutions; this did not deter

some of them from seeking health care. Oldenetti et al. (1996) found that HIV positive

women believed that every woman should have the option of being tested but that HIV

testing should not be done unless counseling and treatment are available. Sobo (1995)

found that women trust clinicians who show empathy and a non-judgmental attitude and

who do not pressure women to disclose their HIV status. Given this, Sobo recommends

straightforward communication to reduce misunderstanding.

Ingram and Hutchinson (1998) reported that HIV positive women felt oppressed

and discriminated against by society and by the health care profession. These women,

they say, use various coping mechanisms in order to lead "normal" lives alternately

concealing their HIV status from strangers or looking for sympathizers in society. In a

follow-up study, Ingram and Hutchinson (1999) say that some women develop an attitude

of "defensive mothering" to protect their children against stigma. These mothers did not

hide their HIV status from friends and family and took extra precautions in their health

behavior and practices. The near-universal directive to reproduce provides a woman with

a different status during pregnancy. "Babies represent sources of love, acceptance, and a

legacy for the future," say Ingram and Hutchinson ibidd: 243) "even for a woman with no

sense of future for herself." Other studies show that guilt and the fear of dying and

leaving children behind can become an emotion that dominates women's reproductive

decisions (Sowell and Messner 1997, Williams 1990).










Much of the researches on cultural and social barriers to prenatal care for HIV-

positive women have been done in the United States. The MTCT problem is greatest,

however, in developing countries. The research I report here contributes to the research

called for by Reeves et al. (1999), among others, on HIV positive women's knowledge

about MTCT, and the barriers that prevent them from using available prenatal and

perinatal care.

















CHAPTER 2
MOMBASA THE RESEARCH AREA


Geography

Mombasa is located off the coast of East Africa. As Kenya' s second city, it is the

main seaport and the capital of the coast province. Kenya has seven provinces; the coastal


province is one of them. The island of Mombasa adj oins the coastal hinterland; it is

symmetrically oval, three miles long and five-and-one-half square miles in area, lying on

a northwest-southeast axis (Stren 1978). The connection of the island to the mainland is

the Nyali bridge in the north, the Makupa causeway to the west, and a daily ferry service

in the south. The whole coastal region has a tropical climate with northeast and southeast

having monsoon winds. The harbor has deep waters providing excellent channels for

anchorage and access for large cargo ships, thus providing access for visitors from around

the world (Ntarangwi 2003).



Ethionia

Turkana

Uganda

KENYA Somalia




Nairobi
Lamu
Indian
Tanzaia Malindi Ocean
Mombasaa

Figure 2-1. Map of Kenya situating Mombasa









History: The Visitors and Administrators

Strobel (1979:22) explains that "in the 750 years of its recorded history prior to

colonial rule, Mombasa absorbed one wave of migrants after another, each contributing

to its culture". Mombasa became culturally diverse due to traders from the Indian

subcontinent, Ceylon, China, and north and central Africa, and administrators from

Arabia, Portugal, and lastly Britain. These latter groups have left a lasting impression on

the society's politics, economy and culture.

Mombasa was an urban coastal settlement according to the geographers, al-Idrisi

and Ibn Batuta who visited the area in the twelfth and fourteenth century. Arabs and

Persians initially came to Mombasa to trade. The Arabs ruled the East African coast due

to wars among the existent feudal rulers at the coast. Conversion of the local inhabitants

to Islam was not an initial goal. According to Pouwels (1973) Islamization in Mombasa

took two phases, with a stronger conversion emphasis after 1300. This has been reviewed

extensively by Berg (1968), Davidson (1991), DeBlij (1968), Mazru'i (1995), Prins

(1961) and Salim (1973). The coastal people named Mombasa, "Mvita" or "Isle of war"

due to the many conflicts, instigated by the Arabs and the Portuguese, and later the Arabs

and the British, and the inhabitants against the intruders.

There was a long period of unchallenged Arab domination which ended when the

Portuguese arrived in Mombasa in 1498. The establishment of Portuguese power along

the coast was greatly facilitated by the tension between the various coastal city-states and

their Arab rulers. The period of Portuguese domination, lasted from 1500-1700, a time of

constant clashes with the inhabitants, with assistance by the Arabs. The Portuguese had a

reputation of greed, corruption and dishonesty (Kirkman 1964, Salim 1973).

Dissatisfaction led to a number of rebellions and revolts with the burning down of









Mombasa on two different occasions. Other than economic interests, the Portuguese

brought Augustinian missionaries to convert the inhabitants but they met with little

success (Freeman-Greenville 1980: xxvii). The Portuguese built forts and garrisons along

the coast in order to control this area of the Indian Ocean. The Portuguese culture and

language made a minor impact on the local Swahili culture (Abdulaziz 1995:144).

However, they introduced crops such as, maize cassava, cashew trees, avocado, guava

and tobacco (Salim 1973:4). The Portuguese withdrew to Mozambique after numerous

rebellions and riots (Kirkman 1964).

Mazru'i (1995:4) explains that there "was a power vacuum in East Africa during

the 18th century" and the early 19th century after the removal of the Portuguese. From

1698, the Yarubi dynasty in Oman placed the Mazrui family as governors of Mombasa,

and they ruled for 139 years. By 1812, the occupation of the Sultan of Oman was more

evident with the presence of a powerful naval and military force in the Indian Ocean,

incorporating the coast of East Africa as part of the Omani kingdom. Abdulaziz

(1995:145) asserts that this was the beginning of a "new era of political, cultural and

economic change" on the East African coast. Other immigrants were brought from other

countries, such as Hadhramut, Baluchi, and India to act as laborers, officials and soldiers.

The local culture and life-style became integrated with that of these immigrants in

language, dress and clothing, architecture and cuisine. The diversity was solidified

through inter-marriage with the local inhabitants. This was to become the Swahili culture

and the people who adopted the language, and customs became the Waswahili. Kiswahili,

the language has a Bantu structure; however Arabic is evident in 40% of its vocabulary,









and there are also a few Portuguese and Indian words. The word "Swahili" in Arabic

means "coast" and Waswahili means people of the coast.

The Arab domination of the East African coast coincided with the ivory and slave

trades Mombasa was a maj or slave receiving port, with some slaves remaining as

domestic and agricultural laborers (Strobel 1979:30). The effort to end the slave trade on

the Indian Ocean was one of the reasons that the British entered Mombasa. Although the

British abolitionists had humanitarian reasons to stop slavery, they also had political and

economic motives (Mazrui and Shariff 1994:31). British colonial rule began in 1895,

ending almost two hundred years of Arab domination. The British took administrative

responsibility from the Imperial British East African Company, and made East Africa its

protectorate with Mombasa as its capital. This changed in 1902 when the capital was

shifted to Nairobi. Roads, railways, and other governing infrastructure were built to

increase security and to improve the political and economic advantage of the British

administrators. These improvements not only altered Mombasa' s economy, but, as the

Mombasa' s importance as a port grew, it also brought an influx of immigrants from

upcountry (Ntarangwi 2003: 34). These new immigrants, whose ethnicities are Kikuyu,

Luo, Luhya and others, were different from the coastal people in culture, religion and

language. These immigrants were perceived by the established society in Mombasa to be

aggressive, and "uncultured" and there was initial resistance in accepting them into

Mombasa' s society (Foeken et al. 2000; Strobel 1979). Some of the so-called new

immigrants have intermarried and assimilated into the Swahili culture, including

converting to Islam, with their offspring becoming Swahili.









The Coastal People Waswahili

Many scholars have tried to determine the origin of the Swahili culture and its

people (Berg (1968), Chami (2002), Mazrui and Shariff (1994), Nurse and Spear (1985),

Salim (1973), Strobel (1979), Swartz (1991) and Willis (1993)). The prevailing theory

focuses on the fact that the initial groups of people in Mombasa called themselves the

"twelve nations" (ithna~shara taifa). These twelve nations are divided into two groups,

one group of three (miji tatu), comprising the WaKilindini, WaTangana and

WaChangamwe, and a group of nine (miji tisa), comprising the WaMvita, WaJomvu,

WaMtwapa, WaKilifi, WaPate, WaPaza, WaShaka, WaGunya and WaKatwa. Each

group, or nation (mataifa), had its own political representative who governed through

Arab and Portuguese rule. This system disintegrated, however, under the British.

Most of the people belonging to these groups referred to themselves by their

ethnicities and do not call themselves Waswahili (this occurred as well when I questioned

ethnicity in this research). According to Salim (1973:1-6) these groups are what

constitutes the Waswahili. He further defines the Waswahili as people of the coast with a

similar language--that is, Kiswahili--and having a culture influenced greatly by the

Muslim faith. He finally claims that "the Swahili do not form one tribe claiming one

ancestor. The Waswahili are the result of mixing and intermarrying between Africans and

immigrants".

Willis (1993:12) argues that "there is no single 'definition' of the Swahili: different

people, in different situations, may appropriate this ethnonym or apply it to others

according to their perception of their advantage". This argument stems from assessment

of the Waswahili in three areas. First, during British colonialism, for the enforcement of

taxation and other laws, the differentiation of "natives" and "non-natives" served as a









basis for people to define themselves to their economic or political advantage (Stren

1978:32). Secondly, after abolition of slavery, a freed slave became Swahili, by

converting to Islam, thereby acquiring status as a non-slave (muungwana). Thirdly, after

Kenya's independence, to be accepted into the new political arena as a mwananchi (a

term reserved for an indigenous African), people who had claimed Arab or Persian

ancestry now had to disassociate themselves from being anything other than African.

Another group of people in Mombasa are the Mijikenda, comprising nine Bantu

ethnicities; the maj or ones are the Digo (almost all Muslims) and the Giriama. The

Mijikenda have also intermarried with the Arabs and Waswahili, some calling themselves

Waswahili, although the maj orities have kept their ethnic identities. Some of the

Mijikenda were also added to this study because of the sharing of culture, particularly in

healing.

How has the history influenced society?: Among these ethnic groups in

Mombasa, some cultural practices are shared while others are not. For example, healing

for high blood pressure (mwajuu) in pregnancy is done by the Mijikenda, but Arab

women use the treatment.

During my fieldwork, I observed and listened to women as they complained about

demands on their time that kept them from taking care of things like preventative health

care. Some of these demands include visiting friends, neighbors and relatives; attending

ritual events such as weddings, circumcisions, births, and funerals; and religious studies.

While these activities take time, they also provide a network of emotional and practical

support, "access to jobs, goods and information" and "insurance against economic and

personal calamities" (Holmes-Eber 2003:9-10).









What Occupies Women's Time in Mombasa? Society and Culture

Visiting friends and relatives: Visits to friends, neighbors or family are made by

women mostly in the late afternoons, but can occur at any time during the day. These

visits are done after women have finished their other duties of cooking, cleaning and

childcare, or for those who work in the formal economy, after work. Fitting in a hospital

appointment for preventative care becomes difficult for some women who have to plan

for visits. The visits are informal without previous announcement and can be a quick

"just checking to see how you are" (nimekuja kukujulia hali) or a full day (kushinda)

depending on the purpose of the visit. Visits are considered social, cultural and a religious

obligation, particularly when visiting the sick. Depending on the duration of the visit,

drinks such as tea, coffee or soda may be served. On these visits, exchange of

information, chit chat or gossip takes place from the latest fashions, births, weddings or

funerals to be attended or checking on other family members. Holmes-Eber (2003) in her

research of women in Tunisia analyzes visits as important survival strategies for women.

In addition, she asserts that match-making and arranged marriages take place as young

people visit and meet at these social gatherings. There is no specific word in Mombasa

that describes the word "visit", except words that explain what the visit is about, for

example "I am going to visit the sick" (nenda kumtizamna mgonjwa) or "I am going to pay

my respect to the deceased family" (nenda ku~wapapole waliofiliwa).

Visits are reciprocated particularly for the sick. A woman who visits others also

receives visitors (atakaet~~~~tttt~~~~tttt watu na yeye hutatttttttt~~~~~~~kikana) when she or a family member gets

sick. A visitor will cook and clean and help with the general upkeep of the house.

Furthermore, if the sick is admitted, the visits continue at the hospital. Hospital

administrators and clinicians (especially those from up-country) voiced concern and









frustration due to these visits, because of the amount of people that come to see or stay

with the patient. Hospital rules that are strict and impose special times and number of

people by a patients bedside are criticized, at times creating conflict between hospital

personnel, relatives or friends. The hospital administrators, understanding the culture,

allow one relative to stay with a patient at all times, and leave this person to be the liaison

to the other relatives or friends not allowed in. The advantage to clinicians is having a

family member to assist in caring for the sick, especially when there is shortage of staff.

The disadvantage however, is the lack of privacy for other patients and taking time to

explain procedures to the patient and relative. Information about the patient's condition

and interaction with hospital personnel is relayed to other visitors. Even an infectious

disease does not deter a family member from staying with the sick. Desertion of a sick

family member is considered inhumane, leading to other community members criticizing,

scolding or ostracizing with comments such as, "how could you neglect your sick?" (vipi

mumemtupa mgonjwa wenu?). These comments are also made if a relative does not take

of a woman who has given birth. Having a sick family member obligates a woman

visiting others, or being involved in social activities. She is expected to take time c

work and stay home to take care of the sick. Other relatives take turns and participate in

the duties of caring. The help from other family members include when and how to seek

for health care providers.

Grandparents or older family members not living in the same household, as well

have to be visited and greeted whether daily or at least weekly, even when they live with

other family members who take care of them. Visits increase when the elderly get sick or

a sick person's condition deteriorates or at the time of death.









Funerals: Before death or when a person dies, the relatives and close friends

gather to pray and perform the last rites. Attending a funeral is assurance that an

individual will get a decent burial at death. A woman's last rites are performed by

women, and men's by men. The corpse is left in the house where she or he died, and if

the individual died at the hospital, the corpse is brought to his/her home for the last rites.

Following Islamic rules of the last rites, the body does not undergo post-mortem unless

foul-play is suspected and authorized by the law. The burial is conducted on the same day

or within twenty-four hours after death for example, a person dying in the night is buried

before sunset on the following day. A corpse that cannot be buried and has to be kept

overnight is left in her or his home. Relatives and friends gather in the deceased home

and Quranic text or special recitations for the soul of the departed are read. At times a

religious teacher (nawalinsu) and his students may be invited to conduct these recitations

during the day before or sometimes after the burial. The one who washes the corpse

(nzuosha nzaiti) can be a family member, neighbor or friend especially for women;

however for men a designated community member has this responsibility. A large ba

(in modern houses) is kept under a special bed without a mattress (kitanda cha nzwak

used just for washing the corpse. In homes that still have beaten earth or mud flooring, a

hole is dug underneath the bed where the water drains. Pregnant women are excused from

participating from performing funeral rites.

During this research, there was controversy about the performance of the last rites

in relation to people who die due to infectious diseases, such as AIDS. The community

was divided, with one group agreeing to adopt the recommendations of HIV/AIDS

activists and health care providers who wanted to implement the use of gloves and special









training to be given to the washers in how to handle infected body fluids. Those who

opposed such interventions argued that such practices would expose the family to the

stigma that their family member died of AIDS, and also dishonor the dead (kutuaibishia

maiti). It was decided that all bodies should be handled the same way whether the

individual died of an infectious disease or not. Wearing of gloves and careful handling of

body fluids is now widely adopted, but not by all.

Close relatives and friends spend three days after the burial at the deceased home.

Money for food is collected from all the attendants and the mourners are fed. On the third

or/and seventh day a gathering that includes neighbors and some community members

takes place to pray for the soul of the deceased (khitma) and a big lunch is done to feed

them. This practice is now discouraged as non-orthodox Islam by the religious leaders,

who argue of its significance, especially since at times it places a financial burden on the

mourners. Despite these protests, some people still continue with the practice.

Weddings: Traditionally marriages were arranged between families, and some

do since a marriage involves the couple, both sides of the family and their relatives.

Endogamous marriages are encouraged, following the Arab intermarriage system, with

parallel cousins being preferred. These are done to "reinforce kin ties, keep wealth in the

family and increase parental control and protection of daughters" (Holmes-Eber

2003:50). Women's education and occupation has increased exogamous unions and

getting more and more societal approval.

Wedding preparations can start months before the actual exchange of nuptials. The

arrangements are done by the relatives with each member volunteering to organize one of

the many festivities that fit into three to seven day. The men may have only one or two










days of organizing, which include the legal and religious aspect of the wedding. The size

of the wedding depends on the wealth of the extended kin. The women involved undergo

beautifying rituals such as removal of all body hair (except the head) through "waxing"

or "threading", plus decorative staining of the hands and feet with henna. These get

together parties might be held at either the bride or groom' s parent's home or at a family

member' s house.

Most of the women feel obligated to participate, as explained by one, "if you do not

get involved, then nobody will come when it is your time" (nisipolorenda, halafu hakuna

atakaekujat~~~ttt~~~ttt~~ nikiwa na langu). What used to be a neighborhood and community affair for

most areas, wedding practices have now changed, with families providing special

invitation cards to minimize the expense of weddings. Despite this change, many families

undergo financial hardship due to these elaborate arrangements. Sophisticated clothes and

expensive jewelry mostly gold are at times bought or ordered from Europe or the Middle

East. The more grand a function, the more status a family receives from the community. I

met women I had interviewed who had complained about not having money to pay for

health care, however they were adorned with very expensive jewels. When I questioned

the attire, one protested that "I do not want to embarrass myself' (sitakitt~~~~tttt~~~~ kujiaibisha). A

woman, who openly displays her inability to dress well or adorn herself with the latest

fashion and j ewels, makes a public statement of being poor (uma~skini), thus shaming her

husband and family. Salim (1973), Strobel (1979) and Swartz (1991) describe further the

details and responsibilities of the sexes, and the daily festivities for each day in a typical

wedding. Ntaragwi (2003) moreover illustrates the types of music for each occasion.










Some women prioritize their time differently, and are very selective of which

activities or visits to attend. These are mostly professional women who are busy and find

it hard to keep up with the day to day family and social activities. Another group of

women are those who attend religious classes (darsa~s). These women excuse themselves

from non-religious related activities in the community. These darsas~~~~ddddd~~~~dddd involve a lot of time

for the organizers and the participants. They take place mostly in the evenings, about

three times a week. I attended one of these meetings, just as I had attended weddings,

funerals, visited a relative's son after a circumcision and numerous visits to sick friends

and relatives. At the darsa, I was invited to talk about my research, and discuss my

evaluation of women' s health issues in Mombasa.















CHAPTER 3
MEDICAL PLURALISM INT MOMBASA

Introduction

Fabrega (1997: 12) has defined medical pluralism as a theoretical framework to

explain the differences between the dichotomies of disease/sickness and illness/healing.

Within medical anthropology, disease/sickness explains the biological or psychological

processes, diagnosed and treated within a Western biomedical framework. Illness/healing

on the other hand explain an individual's and his societal psychosocial interpretation and

management of sickness, (Fabrega 1997, Kleinman 1978, Waldram 2000, Young 1981).

Waldram (2000: 605) further argues that, "every medical system is a cultural system and

is engaged in both healing and curing". The practice of medical pluralism is universal

with the incorporation of alternative or complementary therapy, which may include

homeopathy, herbals, natural healing and holistic therapy. In non-Western societies, the

use of traditional medicine and some of the above practices are incorporated with

methods to include indigenous and religious healing rituals.

The word for health in Kiswahili is afya which is a holistic concept that goes

beyond that set by the WHO to include wholeness, safety and strength. "The healing

processes for ill health include attention to social relationships, emotions and religious

spirituality and conformity with tradition" (Boerma and Bennett 2000: 261). Ndege

(2001: 90) adds that being in good health not only includes the biological functions of the

body, but also embraces the political and economic forces that impact the body (Janzen

1978).










Each healing practice, according to the beliefs of pluralistic health systems, is

incomplete. For example, among the women I studied, biomedicine has antibiotics tl

can take care of respiratory infection, but the antibiotics can not take care of the wind that

might have caused the body's physical imbalance. If any given tradition is incomplete,

then pluralism makes perfect sense. In Mombasa, cultural healing practices include home

remedies, traditional/folk healers, herbal practitioners, Muslim and Christian spiritual

healers, charlatans, drug vendors, biomedical hospitals, and public and private health

centers.

Kleinman (1978: 86) asserts that illness is experienced and reacted to in three

sectors: the folk/traditional, the professional and the popular. He further explains that

groups have "cultural categories that they organize various types of illness and methods

of treatment" (Ware et al. 1989: 24) I have incorporated Islamic medicine and healing

practices within all these sectors since it is part of Mombasa' s pluralistic health care

system

Biomedical Health Care

Biomedical or clinical medicine in Mombasa is organized under the government' s

Ministry of Health (MoH), with headquarters in Nairobi (the capital of Kenya). The

government runs and owns about 5 1 percent of the health facilities countrywide (Owino

1998). Overseers assigned from the government headquarters implement health policies,

maintain quality standards of care and control all resource allocations to provincial and

district health activities. Nongovernmental, private-for-profit and mission organizations

run the rest of the facilities. For further details of the history of health care and the health

care infrastructure in Kenya see Beck (1981), Mburu (1981), Ndege (2001) and

Nyamongo (1998). In addition, Obonyo and Owino (1997), Owino (1998), and Owino et









al. (2000) have written on the financial and managerial challenges Kenya faced frc

independence (and continues to face) and guidelines needed to improve deliverance of

efficient health care services. Health care for all used to be free in Kenya until 1989

when cost-sharing programs were implemented after the introduction of structural

adjustment programs to assist the state with economic health management (Wanyande

1993).

The main maternity hospital in Mombasa, named Lady Grigg, is located at the

Coast General (Provincial) Hospital (CGH). The hospital's administrative responsibilities

are handled by the Provincial Medical Officer and his or her executive team. There are

two ways that women can get prenatal care: through CGH and from the health

department run by the municipal council. The CGH provides prenatal care services under

the preventative health care system. These services are also offered in seven department

health centers in Mombasa. These centers, however, are managed and financed by the

Ministry of Local Government, represented by the local Municipal Council. The

complexity of this system has been summarized well by Schaefer (1981:13 0) who states,

"often the government of the central city has no authority over other towns in the

conurbation, and rival local governments may pursue uncoordinated and contradictory

policies". This lack of coordination was especially evident in Mombasa for pregnant

women who presented with complications and needed advanced health care. Women with

complicated pregnancies are referred to CGH where there are advanced medical facilities.

Communication between clinicians who examine women at the health departments and

obstetricians at CGH is almost non-existent. CGH does not deal only with women with

complications from Mombasa Island, but also from the adj oining districts that comprise









the coast province. This province has a population of over two million. Despite the

inefficiencies at the municipal level, prenatal care services provided for women at the

CGH were well-organized, with formal educational classes given or televised while

women waited for services. The instruction given to women covered nutrition (for them

and for their infant), childbirth, infant care, breastfeeding, and prevention of malaria,

anemia and HIV. I did not observe these classes being offered at the non-government

institutions.

The maj or private (for profit) hospitals in Mombasa are the Aga Khan, Pandya and

Mombasa. These hospitals have physicians who provide care for their admitted patients

and prenatal care in their offices or clinics. These hospitals are efficient and expensive,

charging approximately Kenya shillings (Ksh.) 20,000 to 40,000 (about $ 250-400) for

childbirth without complications, compared to the government hospital or birthing

centers that charge Ksh. 3000-4000 (about $30-50). Women who use the private facilities

are mostly insured, either by the National Hospital Insurance Fund (NHIF) or by private

insurance. In Kenya the NHIF is mandatory for all salaried employees earning taxable

income, though it reimburses only hospital care (Owino 1998).

The nongovernmental facilities include the African Medical and Research

Foundation (AMREF), UNICEF and various providers from religious charity

organizations. Furthermore, there are numerous for profit out-patient clinics manned by

one or two health professionals that charge reduced fees for health care services. In the

late 1980's, the Ministry of Health allowed health care workers such as nurses and

clinical officers (physician's assistants) to engage in private practice (Obonyo and Owino

1997). This government ordinance led to the opening of numerous out-patient health









centers, pharmacies and small hospitals that serve about five to twenty in-patients,

providing curative and preventative health services.

Christian- and Muslim-run not-for-profit charitable hospitals that charge minimal

fees are among these varied health care facilities. My research concentrated on three of

the Muslim-run establishments--the MEWA, Sayyida Fatima and Al-Farouk hospitals.

These hospitals were in neighborhoods where almost all the inhabitants were Muslims.

This proximity increased women's attendance when they needed maternity health care. In

addition, the cost for prenatal care and childbirth was almost a third less than that charged

at the other private institutions. These three hospitals had a total capacity of 80-100 in-

patients. Each had a small emergency room that managed minor cases of immediate care,

facilities for small surgical procedures, a pharmacy, a laboratory and an out-patient

facility. Moreover, they had qualified physicians (some worked privately, some were

employed by the hospital), nurses, midwives and other various hospital personnel. The

maj ority of the staff and their clients are Muslims, though there were a few non-Muslims.

The sense of familiarity that comes from receiving care from staff of similar religious

beliefs and culture increased encourages some women to use these facilities.

Nevertheless, I heard complaints from several women of nurses being unhelpful and

"arrogant." Criticism also stems from inflexibility of hospital staff in rej ecting certain

cultural practices, like the release of a corpse immediately after death. Islamic practice is

to bury within twenty-four hours. This becomes a problem since hospital rules (imposed

by the government) require that all the right documents be files or that a post-mortem be

done before a corpse is released. This tug of war between religion, culture and

biomedicine affects the relationship of the local community and clinicians. Quite a few









community members asked: "What is the use of having a Muslim-run hospital if they

cannot understand our needs?" The wide knowledge gap between health care providers

and their patients or kin at times created tension when they dealt with each other. Some

women offered these conflicts, created by the hospital administrative system, as their

reason for choosing home-based birthing centers.

Birthing centers are operated by nurses, midwives, clinical officers (physician's

assistants) or, occasionally, a physician. There one or two clinicians at these centers

employ a non-licensed assistant to help with management tasks. The volume of patients is

low--from five to twenty parturitions a month. Prenatal care is not efficient or consistent;

some of these centers have a small laboratory that can perform minor services, such as

hemoglobin levels and urine tests. Women are sent to private laboratories and pharmacies

for services if needed. Women who avoid hospitals because of rigidity assert that this

atmosphere is preferable. On the other hand, women who need advanced medical care do

not receive it at these centers, with detrimental consequences for their health. Basic

biomedical equipment is used during childbirth. Instruments are sterilized; birthing beds

are used with stirrups when needed. Minor surgical procedures such as episiotomies and

circumcisions (of male infants) are performed. One of the maj or complications of

childbirth is postpartum hemorrhage. Oxytocin, or ergometrine, a medication to stop

bleeding, and intravenous fluids are given to women who are beginning to hemorrhage

before they are rushed to a hospital that can provide advanced care.

The atmosphere in these centers is relaxed, jovial and comfortable. Women are not

rushed and services such as body massages are available for a fee. Biomedicine, home

remedies and traditional healing practices are combined. For instance, a woman










diagnosed with anemia is given iron pills, advised to drink a mixture of raisins and spices

(sikifabili), and receives advice in the form of a Quranic verse that she can recite to get

rid of ha~ssad (evil eye).

The health care network starts from these neighborhoods maternity facilities

moving up to the Lady Griggs / Provincial hospital where women are referred for

complications. The private hospitals and the CGH have more sophisticated diagnostic,

therapeutic and rehabilitative services. With the HIV/AIDS epidemic in Mombasa, most

of these other facilities do not have the training to assist HIV-positive women or their

infants in therapeutic care during pregnancy or at childbirth.

Traditional/ Folk Medicine

"Healers have for long been treated like trees on savanna farms not formally

cultivated, yet valued and used, particularly by women and children" (Chavunduka and

Last 1986:259). The traditional healer (mtabibu) has been defined as the witch-doctor

(mganga), diviner, medicine man, herbalist or sorcerer. In an urban area like Mombasa,

biomedicine is politically the only legitimate and acceptable form of health care service,

though the herbalists and diviners continue to practice publicly (Mburu 1992). Ataudo

(1985: 1345) describes African traditional medicine as "the totality of all knowledge and

practices, whether explicable or not, used in diagnosing, preventative or eliminating a

physical, mental or social equilibrium and which rely exclusively on past experience and

observations handed down from generation to generation, verbally or in writing".

Traditional healers in Mombasa are both male and female and they practice for

both sexes depending on ailment. However, pregnancy related illnesses are treated by

traditional birth attendants (TBAs) who have various degrees of knowledge in herbal

remedies. In addition, practices such as massage therapy are done only by women









healers. Healers as well use an "extensive system of classifying illnesses according to

signs and symptoms and suspected cause. Their system is dynamic and increasingly

incorporates biomedical knowledge" (Boerma and Bennett (2000: 262-263). This was

evident during observations and interviews with TBAs. Almost all TBAs stated that they

used gloves and dettol (antiseptic solution) while assisting in childbirth. I observed them

giving pain relievers such as (Panadol/Tylenol) and Chloroquin to treat malaria. In

Mombasa, TBA's are sent for educational training to the provincial hospital to learn

about complications in childbirth and prevention of HIV from contact with body fluids.

This has been promoted and encouraged by UNICEF. The TBAs who receive such

training are registered with the neighborhood chief. Mombasa Island has seven chiefs

who function under the administrative structure of the Municipal Council. These chiefs

have the responsibility to register births and deaths in their locations. They also keep a

log of all practicing TBAs. Not all women who give birth in the neighborhoods are

assisted by registered TBAs. Almost all of the TBA' s stated that they did not have formal

education or training, but had learned from observation. They stated that they received

their training to assist in births from their mothers, grandmothers and/or other female

relatives. A few TBAs stated that they had worked in hospitals as nursing assistants and

had learned from observation. There were two TBAs who declared that it was a spiritual

obligation, since they were "called" to healing. TBAs charge about Ksh. 2000 (about

$25). They do not demand payment before they render their services, and some barter for

other goods or services when financial payment is impossible. They are also flexible.

They go to women' s homes before a birth, and will stay to assist with the care of the

mother and baby if they are not called away for another birth.









During the interviews for this study I talked with 12 women who had assisted in

births, but I spent a lot of time with and directly observed two TBAs (see Chapter 4) who

were conducting the most deliveries in Mombasa. I also interviewed five male healers.

These interviews were not included in the quantitative analysis, but they added depth in

understanding healing in Mombasa. The purpose of healing, I was informed was to regain

'balance' or return the body to the state of 'wellness' by finding out what has afflicted the

body or interrupted or disturbed its function. These healers at times had their own herbs

and remedies which they prescribed and offered to their patients. Alternatively, they sent

their patients to herbalists with prescriptions.

Herbalists are important healers in Mombassa, they are mostly male, and their fees

vary depending on the ailment. The herbalists have an empirical knowledge of the

midicinal properties of selected leaves, barks, saps, roots and other natural products. The

use of herbal medicines begins at home in Mombassa. One tree, the muarubaini, was said

to be useful in the treatment of treat forty different ailments. Drinking a boiled potion

from the leaves of the muarubaini, treated fever associated with malaria, flu or

pneumonia. The herbalists in their shops or at the market prepared and sold what could

not be provided in the home. On the streets are also charlatans who claim knowledge and

competence in healing but prey on individuals who are desperate for treatment. There are

two types of herbalists, one who has a diagnostic and treatment center, while the other

sells his ware at shops or the market place (Beck 1981, Good 1986, Mburu 1992). The

most frequented herbalists in Mombasa are in two shops, one located in Old Town,

owned by an Indian healer. He stated the shop has been family owned since 1873, and

supplies the town with therapeutic treatments from India, China and the Middle East. The










second shop in Mwembe Tayari provides more local herbal remedies, though here, too,

non-local medicines are ordered from Tanzania and the Middle-East. The owners of both

stores explained that they did not diagnose or prescribe treatments. There are other

herbalists across Mombasa. Some sell their treatments at the local market. Others sell

along the road, where people stop to make purchases. Women herbalists who treat

pregnancy related conditions practice mostly from their homes, though a few have stalls

at the market (see Chapter 4).

Diviners are perceived to have a special "gift" or supernatural powers. They vary in

skill levels, specialization, knowledge and beliefs, the types and organization of therapy

they provide, and personal mannerisms. Diviners in Mombassa claim, and some are

believed to have the ability to diagnose and prescribe treatments, though do not offer

treatments. The diviner "gives the ultimate etiological conditions of a psychic, somatic or

psychosomatic disorder, interpersonal alliances and conflicts" (Mburu 1981:172). The

importance of balance in interpersonal relationships is part of being a moral person.

Fairness in the treatment of others protects a person from misfortune and illness. Wishing

ill or hostility on another person also brings harm to oneself (mchimba kisima huingia

mwenyewe). In addition, unresolved social relationships are viewed as causes of poor

health. For example, a pregnant woman's weight loss might be attributed to poor

nutrition, her relationship with her mother-in-law (who might not have accepted her) will

also be seen as associated with her poor health.

A common Swahili is that "daktard'~'~d~d'~'~d~d'i si M~ungu" (the "Western doctor is not God")

leads individuals to seek other local traditional/religious therapists. The incorporation of

Muslim diviners/healers differentiates the use of diviners from other non-Muslim groups.









The Muslim cleric, who is almost always a man, has a role as a diviner by using texts

from the Quran, astrology, numerals or rosary. He also divines through dreams, spirit

possession and necromancy (1980: 84).

Islamic Healers

"Islam affirms the power and will of Allah in all things, including suffering"

(Whyte 1997:47). Faith, illness and healing go hand in hand and it is common to hear a

sick person and his or her therapy managers to state that the outcome of the illness is

Allah' s will. Cure does not take place if not willed by Allah, and fatalism is the doctrine

sometimes adopted by believers (Feierman and Janzen 1992).

Islamic medicine in Mombasa dates from the 8th or the 10th century (Trimingham

1980), and is still practiced. Islamic healers incorporate Prophetic (Arabic) and Galenic

humoral medicine to view health and assess the body's response to illness. Humoral

medicine emphasizes on the hot/cold dichotomy, specifically in foods and the

environments. Greenwood (1981) and Morsy (1993) provide a detailed narrative on

humoral medicine in Morocco and Egypt which jibes with similar beliefs in Mombasa

(see Chapter 6). From a similar perspective, but adding women's knowledge about

pregnancy and the practices surrounding childbirth, Obermeyer (2000) has investigated

medical pluralism and humoral medicine in Morocco, while Mandersen (1981) describes

humoral practices and childbirth in Malay.

The imbalance demonstrated by disease is said in this system to be due to features

of physical and spiritual bodies. Physical imbalance can be caused by exposure to the

environment. Imbalance related to the environment is caused by the air or wind (upepo),

cold or hot temperatures. A woman complaining of having a fever (homa) could be

reacting to her body's discomfort to environmental heat or cold.









Food intake, lack of sleep or rest, and one's emotional state (Abdalla 1992: 182)

are related to certain illnesses. Emotional state is similarly linked to 'balance' or

'imbalance' of hot and cold. A hot tempered person suffers from headaches, while a cold

natured individual gets depressed (baridi ya bisi). Healing consists of rest, diets, fasting,

an array of medicines, and the extraction of impurity by bleeding, scarification or

branding, vomiting or use of enemas (Slikkerveerl990).

There is also a belief that spiritual beings cause illness. Morsy (1993: 1 11)

describes them as "subterranean beings" and assigns their effects into two categories,

direct and indirect. Direct spirits afflict individuals through possession, while indirect

beings are controlled or manipulated by others through sorcery. Waite (1992: 214)

explains that "spirits are believed to bring certain kinds of illnesses and other afflictions

to individuals, to families and to the whole communities". She specifically identifies

ancestral spirits, which represent the founders of an individual family. In Mombasa these

are termed nzajinni ya ukoo, and those of the community/territory (nzajinni wa nzji).

Spirits in Kiswahili are called jinni (plural nzajinni), pepo or ruhani. These are

mischievous and although they may cause discomfort, they do not cause serious illness or

death. For instance, a woman who has a ruhani can be pregnant for more than a year, (see

Chapter 6) and will not deliver until the ruhani is appeased.

Spirit possession can take many forms, from mild affliction (where a person

portrays physical discomfort) to altered social behavior. Serious symptoms of suffering

include body weakness, loss of appetite, loss of weight, headaches, and sometimes

shaking of the body. Sorcery accusations reflect strained social relations and could be due

to revenge. Sorcery can be used to create infertility, impotence or deaths of infants.









The "evil eye" (ficho) or ha~ssad, refers to harm inflicted on an individual due to

feelings of envy or j ealousy. In Islam, ha~ssad is "legitimized by reference to Quranic

descriptions of the malevolent power of the ha~ssid or possessor of the evil eye (Morsy

1993:110). Hassad is associated with creating misfortune, illness and even death. A

woman who says that someone else's baby looks healthy might be the target of blame if

that child suddenly becomes ill. Her eye, whether consciously or not, would be the cause

of ill-health. Women who have miscarriages or infant deaths might be asked if they are

obj ects of ha~ssad (fe umehusudiwa). Moreover, when a multitude of misfortunes occur in

a household, the inhabitants question if the home has ha~ssad, which. if true, would

require a healer to diagnose and remove the cause of the ha~ssad.

Hassad is different from sorcery which is associated with shirk or the acceptance of

a power greater than God--the gravest, most unpardonable sin in Islam (Feierman and

Janzenl992). Superstition and practices associated with it are slowly diminishing due to

Western education and culture on the one hand, and Islamic orthodoxy on the other.

Muslim women who still go to diviners or healers that believe in sorcery do so secretly.

This practice is associated with heretics and therefore sinful ibidd).

Sharifs are people who claim genealogical descent from the prophet Mohammed.

They assert, "or are imputed by their followers, to possess baraka or special blessings

from God, which can be used in healing" (Beckerleg 1994). Besides the sharifs, there are

also scholars of the Quran (maalims) with knowledge of Islamic law and Arabic medical

texts. This body of knowledge is taught locally or in the Middle East. The emphasis on

treatment for hassad or spirit possession is based on theories of balanced hygiene and

diet, and also, at times, exorcism. Portions of the Quran are prescribed, and written to be









worn as an amulet. It may also be written with food coloring on a plate, which is rinsed

out and given for healing or prevention. Although non-religious, some Muslim healers

use drumming (ngonza) for ritual therapy. Janzen (1978: 21) has studied healers and the

use of ngonza in central and Southern Africa and explains that ngonza is used for ancestral

worship, while divination and healing (ngonza za kutibu) are used for healing.

The Popular/ Lay Sector

Dean (1989: 117) defines self-care as the actions that "represent the range of

behavior undertaken by individuals to promote or restore their health". Kleinman (1978)

states that in both Western and non-Western societies, individuals self-treat 70-90% of

health problems in the home. These decisions to self-treat are made by laypersons who

face real symptoms and who seek to improve their health without medical supervision. A

layperson may choose to delay professional assistance until there is failure of home

remedies or worsening of symptoms.

The utilization of Western pharmaceutical and local herbal remedies is widespread

in the homes in Mombassa. Ethnicity, social class, education and gender play an

important role on influencing how home remedies are undertaken. Women and the

elderly tend to self-treat more than others. Geissler et al. (2000) found in Western Kenya

that the use of home remedies and self treatment starts with primary school aged children,

beginning with treatment of minor ailments, such as headaches, body pain, coughs and

malaria. This is also common in Mombassa. Added to home remedies are the prescription

and non-prescription medicines that are received from friends and relatives who work in

dispensaries or hospitals. With chronic illness, self-medication is at times in conjunction

with prescribed medicines. Individuals in a family share and use prescribed medications






44


without seeing a physician because the treatments are available at home and because it

decreases the hassles one has to endure at the local hospitals.















CHAPTER 4
METHODS OF DATA COLLECTION

Introduction

Methods in social research consist of observing, listening, asking and reading. In

this study, I used all of these general methods to study the meaning of health behavior

among some women in Mombassa. In this chapter, I explain the specific methods that I

used, including a questionnaire and participant observation, and how I selected the

sample of women I studied. As a native of Mombassa, I encountered some problems in

collecting data there, but I also had some advantages. I explain these problems and

advantages in this chapter as well.

Research Design and Objectives

One advantage of being a native of Mombassa is that I already am fluent in the

local language, Swahili. I was educated as a nurse in Nairobi and practiced in hospitals

there, plus in Mombasa for 6 years before coming to the United States. Over the years I

have maintained both family and contacts within the medical community in both places. I

have a few family members in Mombasa, during this research I lived with one of my

cousins and her family whose residence was in Mwembe Tayari which is in the middle of

town. This facilitated easy ambulation around town, and where places were not within

walking distance, public transportation (or the matatu) was easily available. With all of

this social support, I was able to conduct this study in six months, from June to

November 2003. l used Handwerker' s (2001) guide on how to perform an efficient and

"Quick Ethnography", plus Bernard (2002), and Patton (1990) on how to design and










perform fieldwork. During the summer of 2002, I went to Mombassa to reestablish

connections with people who would become my key informants, including physicians

and nurse-midwives who trained in 1977-1982 when I did my nurse/ midwifery training

in Nairobi, Kenya. These gatekeepers became my first informants and helped me to

determine what was feasible for my study. They told me which officials to contact when I

returned a year later for fieldwork, and they continued to help me with preparations by e-

mail and telephone after I returned to the United States to complete my proposal, develop

my initial questionnaires and received Internal Review Board (IRB) approval from the

University of Florida. Before leaving the United States, I as well mapped out a time

schedule and structure for data collection.

I spent the first two months in Mombasa building a foundation for fieldwork. This

consisted of initiating pertinent conversations, intense listening and informal interviews -

what Handwerker (2001:106) terms, "first and second order gossip." During these two

months, I also visited official and mapped out interview sites. Data collection and

recording, however, was continuous, from the time I arrived in Mombassa until the day I

left. I started with general, grand-tour questions, as Spradley (1979) called them: "Tell

me about problems that women have here with health care?" "Do you have any problems

with health care?" and so on. These questions elicited a lot of information very quickly

about health issues faced by women in Mombasa and helped me establish clear

obj ectives.

My obj ectives were:

1. to describe Muslim women's knowledge and attitudes about mother-to-child HIV
transmission

2. to describe the health care decisions made by Muslim women during pregnancy
and to identify patterns of behavior in seeking prenatal health care









3. to identify and describe the health care facilities used by Muslim women during_
pregnancy and childbirth; and

4. to determine the factors that predict whether Muslim women make adequate use of
maternity care in Mombasa.

Native Ethnography

As a native going home to conduct doctoral research, I had some advantages, but

also encountered problems that outsiders would not have experienced. Clearly, native

ethnographers have a more difficult time maintaining obj activity than would someone

coming in fresh from the obj activity than would someone coming in fresh from the

outside. I realized as I did this research that there might have been cultural patterns that I

missed, taking them for granted patterns that, as Bernard (1996: 154) observes, an

outsider would see right away. On the other hand, as Bernard and Salinas Pedraza say

quite explicitly, (1989:5) "all ethnographies are subjective and selective. "The object in

social science is not to be devoid of an agenda. This is clearly impossible. The object is to

maintain standards of data collection that eventuate in credible work. Anthropologists are

enj oined to conduct research from a position of cultural relativism that is, to avoid

making judgments of the cultures we study. "Each way of life," we are told, "should be

evaluated according to its own standards of right and wrong" (Walbridge and Sievert

2003:2). I duly entered the preliminary stage of my research in 2002 without

preconceived ideas about what I would find, but I returned that year with obj ectives and

hypotheses. The participant observation data I collected were verified before leaving

Mombasa with key informants for variability and accuracy.

On the positive side, being a native of Mombasa made it possible for me to conduct

this research relatively quickly. I was accepted quickly by medical service providers as a

member of their community and by Muslim women informants as someone with whom










they could speak frankly in their native language, using the kind of idioms and discourse

cues that native speakers everywhere rely on for deep communication. As a result, I was

able quickly to understand the issues that were important to these women. A lot of the

nurses express pride in the fact that I was studying for an advanced degree, plus

impressed that I went back "home" to do this research. Many stated that once people

leave they do not want to get back. The acceptance and cooperation by some of these

nurses, particularly Sister Asya (as she was called by most of those who knew her) was

particularly important. She took me under her wing and introduced me to other clinicians

and key people in neighborhoods that I did not know personally or had forgotten about.

Sophia, another one of my cousins, helped me establish relationships with traditional

birth attendants, herbalists and Islamic healers whom Asya did not know. Michrina and

Richards (1996:75) observe that "there are two types of people in the field, those who are

knowledgeable and articulate, and those who can help you make contacts within your

group of study." Asya and Sophia had both of these qualities and were invaluable to my

research, but the point I want to make here is that my relationship with them was based

on the fact that I was one of them a Muslim woman health-care provider.

On the other hand, familiarity also breeds distrust. Concurrently with my study,

there was a study going at one hospital on a drug (nevirapine) to reduce mother-to-child

HIV infection. I was requested by the nurse in charge of the study not to interview the

HIV positive women, because the woman did not want their identity known by anyone

who might know them or their families. Other informants agreed to be interviewed, but

were clearly uncomfortable and guarded, also not wanting to disclose personal

information to someone who might know people in their families. For example, in one









interview with an acquaintance I sensed her discomfort from the very start when I asked

about her marital status. She had heard, she said, that her husband had taken a second

wife, but had not openly informed her, so she pretended not to know. She hoped, she

said, that I would keep this information confidential since, as long as her husband thought

she was not aware of his action, she would not have to share days with the other wife.

(Polygynous marriages are common in Mombasa and co-wives can demand to have the

husband share days between households). My first priority, of course, was to conduct my

work without doing any harm. This meant that I had to be alert to the need for

confidentiality at all times and for keeping informants plus advisors anonymous. Except

for some consenting individuals such as Asya and Sophia, pseudonyms replace names of

all informants in this study.

As I did my fieldwork, I ran into old friends and acquaintances. I accepted

invitations to weddings, was informed about funerals and social or religious activities.

Most of these events became information grounds for my research and also provided a

needed distraction from work. At these function with friends I was able to discuss

informally various issues surrounding women's health and particularly preventative care.

However, these outings were also a distraction because of the short time in the field and

eventually they became tedious. In addition, I lived in the middle of town with a relative

and her family in the neighborhood of the people I was studying. This was perfect as a

participant observation field site, although I did not encounter culture shock, there were

many changes in Mombasa since I left the island. I have lived in the United States for the

last twenty years, and although I have gone back every other year to visit, these short

visits had not prepared me for the changes I would find in my longer stay for fieldwork.









For example, public transportation workers found it strange when I asked them to tell me

when I needed to alight at my destination. The names of places were the same, but the

mode of transportation had changed. Public transportation was no longer with buses, as

had been the case when I lived there earlier, but with fast moving vans called matatus. Of

greater significance, despite the many benefits of native ethnography, I found myself

critically examining my relationship with both of my own societies, the one in Mombasa

and the one in the United States.

Sampling Design

My obj ective was to interview between 250-3 00 Muslim women who had

delivered no more than eight weeks prior to the beginning of the study. According to the

Kenyan national census, there were approximately 48,000 women of reproductive age in

Mombasa Island in 1999. Figure 3.1 shows a map of Mombasa with 13 areas marked for

high concentrations of Muslims and six health care facilities used by Muslim women. I

screened potential participants for this study at each of the six facilities and also

interviewed some women at home to capture some of the 5% of women who do not

deliver at any of the health-care facilities shown in Figure 4. 1. There are three private

hospitals in Mombasa. I did not interview at these facilities because they are used mostly

by women of higher socioeconomic status and who are, therefore, likely to know about

and use effectively, all available health-care resources (Enderlein et al. 1994, Ivanov and

Flynn 1999, McKinlay and McKinlay 1972).

During screening, I sought to maximize variation in age; ethnicity, education,

parity and socio-economic status in order to maximize intra-cultural variation (see

Appendix 1 for the full questionnaire). Table 4.1 shows the distribution of the sample

across the seven venues. With this purposive sampling strategy, I was able to interview










280 Muslim women who had delivered recently, whether in a hospital or other health

facility or at home. Of the 280 interviews, 265 had complete information and consist of

women during their six weeks postpartum period. These interviews are the subj ect of the

analysis in Chapter 5. Additional information gathered during this study has been added

to explain women's health seeking behavior and add to the qualitative analysis in Chapter

3 and 6. In addition, I interviewed several clinicians, Islamic healers, traditional healers

and birth attendants, and Islamic religious leaders (Imams) about Muslim women's

maternity health, particularly in relations to HIV/AIDS.


1. Tudor
2. Ziwani
3. Majengo
4. Spaki
5. Kaloleni
6. Bondeni
7. Kilifl
8. Kidogo Basi
9. Kuze
10. Makadara
11. Mwembe Tayari
12. Englani
13. Ganjoni






A. Coast General Hospital
B. Sayidda Fatima
C. MEWA
D. Al-Farouk
E. Spaki Birthing Center
F. Kibokoni Birthing


Figure 4-1. Data collection sites









Table 4-1. Interview sites
Location of data collection Number of interviews conducted

Coast General Hospital 50

Sayyida Fatima Hospital 50

MEWA Hospital 50

Al-Farouk Hospital 20

Spaki Maternity Home 20

Kibokoni Maternity Home 20

Home visits 55


Data Collection

Interviews from the questionnaire: The content of my questionnaire is based on

studies of maternity care by Celik and Hotchkiss (2000) in Turkey, Chapman (1998) in

Mozambique, and Magadi et al. (2000) in Kenya. I added questions about knowledge of

HIV/AIDS and its prevention. To pretest my questionnaires, I contacted the owners of the

two home-based birthing centers in Mombasa and obtained a list of mothers in the two

respective neighborhoods who were clients. I interviewed ten mothers in their homes and

tested the questionnaires. I recited the informed consent protocol to each pretest

participant in Kiswahili, and each of them and received their permission to continue with

the understanding that I would hold their information in confidence. After ten interviews,

I learned what worked in the questionnaire and what needed rewording. I wrote the

questionnaire in English and translated it into Kiswahili, taking care to frame the

questions properly in the local idiom. For example, the question "did anybody help you

decide when to start prenatal care?" a direct translation would sound curt and provide a










yes or no answer. This would have to be followed with "whom?" However, rephrasing it

by asking, "mshauri wako ni nani ukitaka kwenda kupima?" ("Who assisted you in the

decision to prenatal care?), would provide both answers. A few of the respondents that I

pretested the questionnaire on were uncooperative, giving short, abrupt answers; some

were reticent because they felt embarrassed by the questions, while others were verbose.

After correcting the questionnaire (see Appendix D), maj ority of the respondents were

very cooperative. I controlled the interviews by leading and providing the appropriate

verbal and non-verbal feedback.

Structured interviews: The questionnaire consisted of structured and semi-

structured interviews. The structured component comprised a series of items on socio-

demographic features, and some questions on the availability of medical insurance.

Marital status a socio-demographic feature that usually elicits a simple answer was

quite complicated. During the pretest, I found that some women hesitated to answer a

query about their marital status and would not affirm or deny whether they were in a

monogamous or polygynous relationship. One woman responded: "How would I

know?,Maybe I am the only wife, and maybe I am not." Thus, in addition to the usual

"yes" and "no" answers for this question, I wrote side notes to include women's added

responses. The question on occupational status also caused some difficulty. A number of

women initially said that they were housewives, or provided one occupation. However,

with time I noticed some were involved in different trading practices from the home. I

reworded the question to include women's activities or jobs that supplement their

income.









Education, both secular and religious, is an area of great concern to the women I

interviewed. They voiced their frustration at not being able to continue with their

schooling because of cultural or religious restrictions, either as understood by them or as

imposed by their families.

Other components of the structured questionnaire included education (both secular

and religious) of the spouse or partner, spouse' s occupation, and whether the spouse or

partner was employed in Mombasa or resides elsewhere (approximately 15% of partners

in this study live or work for prolonged periods out of Mombasa). I also asked about

whether the partner had medical insurance.

Finally, I assessed socioeconomic status with data about the status of the home. I

asked whether a woman owned or rented the home she lived in; whether the home had

electricity; and the source of water for the home. There were three sources of water: tap

water (from indoor plumbing), well water, and water bought from an outside source. I

observed women spending a lot of their day either collecting water or waiting for

someone to deliver water. Piped water in Kenya is state controlled, and when there is a

shortage, it is rationed to certain hours of the day. Water is sold from state-run

neighborhood stations that open from 6 a.m. to 5p.m. For a payment of a few Kenyan

shillings (Ksh.) 25 which is about U. S. 32 cents, water can be delivered to one' s home,

but if the deliverer is busy, waiting for water delivery could use up the whole day. The

house I lived in used well water for every other need, except drinking and drinking water

was bought twice a week. I had the experience of wasting most of a day waiting for

drinking water to be delivered. I understood when women complained and stated their

frustrations about access to water and their relief when water arrived.










Finally, a section of the structure was about women' s awareness of how HIV might

be transmitted from mother to child. If a woman said that she knew the manner of

transmission, then the next question was about the source of her knowledge: word of

mouth, school or college, a health care provider, or the media (television, newspapers, or

radio). A follow-up question probed whether the woman thought her knowledge had

changed her behavior. I assessed behavioral change by asking if the women had been

tested for HIV, and if the test was positive, if she had delivered in a medical facility that

offered procedures to prevent passing the infection to the infant. Although this last

question was placed under the structured interviews, it could as well belong to the semi-

structured section.

Semi-structured interviews: The semi structured component of the survey dealt

with women's pregnancy and childbirth experiences. These experiences are private and

personal and were embellished and dramatized or downplayed, depending on each

woman' s circumstances and perception of those circumstances. I was able to interview

each woman only once and allotted up to two hours for each interview. I was, however,

sometimes unable to complete the work in this time. Some of the narratives were j oyous,

but the heartrending experiences of others were so emotionally wearing, on me as well as

on the narrators, that we often had to take breaks in the middle of the interviews. Some

women had complicated pregnancies and were strong narrators, while others were first

time mothers without complications. This, too, played a role in how much time was

needed to complete each interview. During the open-ended narratives, women expressed

their relief or frustrations about pregnancy and childbirth and mentioned people who had










participated in their j ourney to motherhood, including partners, family members, friends,

neighbors or health care providers.

In this section of the survey, I also developed pregnancy histories: number of

children, miscarriages, abortions, and stillbirths. I felt that many respondents answered

these questions truthfully, except the question about abortions. Abortion is illegal in

Kenya and it is forbidden in Islam, but it is widely known that Kenya has a high rate of

unwanted pregnancies that lead to abortion (Bauni and Jarabi, 2000). One of the leading

causes of hospitalization in Kenya in 19991 was admissions after abortions. Data on

abortion prevalence between provinces showed the Coastal province (including

Mombasa) had lower rates of number of admissions than all other provinces in the

country (Ministry of Health Report 1996-1999).

I inquired about the date of conception, when and where prenatal care was started

or continued, and who assisted or impeded these decisions. I asked about transportation

to and from the clinic and whether the woman liked or did not like the health care center

or provider. Women had a lot to say about the health care system (see Chapter 5). In this

final section, I explored health care decisions that is where, when and why respondents

had begun treatment when sick during the pregnancy. Answers provided were further

probed for diagnosis given, length of treatment and effectiveness. I was able to extract

from these data a taxonomy of the maj or illnesses or problems that are associated with

pregnancy, the type of healer used, and a description of the treatments The main

conditions that were consistently mentioned were homa (fever); anemia; shango (vaginal

discharge), possibly due to fungal or bacterial infection; body aches and pains; and

SThe updated Ministry of Health report for the years 2000-2003 were not published while I was collecting
this data.










mwajuu, with some symptoms that resemble high blood pressure in pregnancy. Some of

these names of illnesses, such as mwajuu and shango were unfamiliar to me, despite

having practiced nurse- midwifery in Mombasa from 1982 to 1983. I was also unfamiliar

with some of the treatments for illnesses that were mentioned, including some home

remedies, some traditional and Islamic healing practices, and even some treatments used

among various ethnic groups living in Mombasa. "Even the most experienced of 'native'

anthropologists," said Narayan (1993:683) about her ethnography in India, "cannot know

everything about his or her society."

The Research sites

As shown in Table 4.1, I did participant observation at four hospitals, two home-

based birthing centers, and visits to mothers in their homes. In the hospitals (Coast

General, MEWA, Sayyida Fatima and al-Farouk), I observed women as they came to

clinics at three different stages: (1) for prenatal check ups, (2) during postpartum

assessment, and (3) when they brought their infants for the six-week post-delivery

evaluation. The second and third stages were logistically feasible; for this study.

Coast General Hospital the waiting room: At Coast General, women brought

their babies for a six-week post-delivery checkup on Mondays, Wednesdays and Fridays

between 8a.m. to 1p.m. These hours were hospital policy and were rigidly enforced.

Women who came late did not find a clerk to give them a check-in card or see a health

care provider. The benches were full by 7a.m. and a quick hustle ensued to the clerk' s

desk as he sat. First, women had to register their babies into the hospital system and

receive a patient number. Next, they had to pay for services in another room. Then,

women waited in a second line for a nurse to check the baby's weight and temperature

and assign them a room or cubicle to see a clinician. This process, including the checkup










by the clinician, took from three to five hours. Many women grumbled and expressed

frustration or sighs of resignation during the course of a normal day at the clinic. Some

infants cried while others were continuously breast, or bottle-fed. Mothers changed

diapers while waiting to be seen. I found a quiet comer and called mothers aside for

interviewing. I asked the other mothers to reserve the informant' s space in line, so that

she would not miss her turn to be seen by a clinician. During these moments, I had the

opportunity to listen and observe the interaction between the women, the health care

providers and other hospital personnel.

This waiting to be seen by a clinician was for well and sick babies and there was

constant commotion as women moved from one area to the next. The whole area was

open except for walled partitions. Once, a mother began wailing as her child died in her

arms, waiting to be seen. I learned later from the matron-administrator of the clinic that

women were supposed to take very sick infants to the emergency room. This was not

something that was widely known or understood. In fact, I had to ask about this incident

to find out that it was possible for mothers with very sick infants to get quick treatment.

This event was so distressing to me that I stopped interviews for the day and went home.

Coast General Hospital the postpartum ward: This is part of the maternity

floor where women stay to recover after childbirth. Women stay for 2-5 days post-

delivery if there are no complications and leave after payment for hospital services. Some

are being given medication intravenously and some require blood transfusions due to

complication in delivery. Other women are well enough to walk around to visit each

other, or go back and forth to the toilet. Infants are either asleep, breastfeeding or having

their diapers changed in this area. The room was quiet, except for an occasional nurse










passing by on errands. I spent the mornings in the mother/baby clinic, and afternoons and

evenings conducting interviews in the post-partum area. I left during visiting hours to

allow family and friends to visit. I would inquire from the nursing staff which patients not

to disturb before interviewing.

MEWA / Sayyida Fatima and Al-Farouk hospitals: These hospitals were

designed to cater to a Muslim clientele. Although the administrators and health care

providers are Muslims, less than 15% of respondents stated that they chose these

institutions for religious reasons. As I will explain in the following chapter, these

hospitals were mostly chosen because of distance, cost, and the availability of specific

services.

As with Coast General, I conducted interviews with mothers who brought their

infants for a well-baby check after six weeks and in the postpartum ward. Compared with

Coast General, service at these two Muslim hospitals was much quicker. The average

waiting period was about an hour and all procedures were done in the room with a nurse,

though a physician saw patients when necessary. I asked to conduct interviews with the

women before they left the hospital. I also spent time here observing how women

interacted with each other and with health care providers. I noticed that unlike the other

government clinics prenatal classes were not offered, and women left quickly after

receiving services. In fact, I had a hard time getting some women to stay for interviews.

Overall, though, I was able to interview most of the women who I approached. One

reason for my success, according to other nurses at these two hospitals, was that I dressed

in a bui bui or abaya, the black overcoat and scarf worn by almost all Muslim women in

Mombasa. Had I dressed as hospital personnel women hurrying to leave after being seen









would not have been as ready to linger and sit for an interview. My dress as a Muslim

woman was a cultural asset and helped me to develop rapport with potential informants

(see Warren and Hackney (2000:22) for more on the importance of dress in Hieldwork).

Time spent in the hospitals helped me develop close relationships with the

clinicians. In one institution, I was asked to assist with deliveries when the hospital was

short staffed. This would have allowed me to move entirely into the role of full

participant as observer, but I declined politely and disengaged in order to maintain a

different relationship with patients than that of the staff. I opted for more detachment and

less engagement, as Hayano calls it (1979: 113). Balancing multiple identities as nurse,

native and researcher was a constant in this study. Opting for a more engaged role as a

clinician might have produced more data, or different data, of course, than those I was

able to collect.

Spaki and Kibokoni maternity homes: In these two biomedical facilities, women

were observed as they came in for prenatal or postpartum visits. Others brought male

infants for circumcision, or pregnancy related problems. Deliveries ranged from one to

two a day, recitations from the Koran was done while the women were in labor, and

women were also encouraged to recite from the Koran in order to distract them from the

pain and provide spiritual comfort. I asked women specifically why they had chosen to

use these maternity centers. The environment was relaxed and j ovial, and if the women

had not stated their specific reasons for coming, one might assume they were there for a

friendly social visit. I did twenty interviews at each of these two homes and Hyve more in

each neighborhood to get opinions about these homes from women who did not use them.

I also interviewed the nurse, the assistant and the surgical technician about their









techniques and their rapport with the people they served. With my knowledge as a

clinician, I could not help but judge the care given to women. One of the two maternity

homes did not have a full-time qualified practitioner, and some of the decisions of the

practitioner on hand were not reassuring. Once, when a woman came in complaining of

premature labor, she was not referred to a hospital where she could receive urgent care.

Instead the patient was massaged and sent home. I provided general suggestions in my

discussions with the practitioner as we compared notes about different ways to assist

women and improve their health care in various conditions, but I did not intervene

directly with nursing or medical given.

Mama Msena and Bi Zuena Traditional birth attendants In comparison to the

home-based maternity clinics, where there was a semblance of biomedical influence,

these homes were regular living arrangements with a room assigned for assisting in

childbirth. The term for one who assists with childbirth is mkunga or mpokeaji which

translates as "one who receives" or assists. Both women were warm, motherly and were

referred to as 'mother', 'aunty' or 'grandmother' by their clients, as if these traditional

birth attendants were members of the clients' families. As I visited these homes, I

realized they were not only used for childbirth, but for advice on child rearing

(particularly of daughters) and for counsel on marital relations. It was definitely a

women's domain. Men who stopped in were on errands for their wives.

The birthing rooms in both homes were empty, except for a bed with a thin

mattress, covered in plastic, and a pillow. The patient had to bring her own wraps, or

khangas, which are colorful rectangular cloths, 1 by 3 yards in width and length. These

khangas had multiple purposes and were used as a bed covering, or as a body wrap while










the woman was in labor, or to cover the baby before going home. Women who came to

deliver were also instructed to bring their own surgical gloves (a recent practice that has

been encouraged since the advent of HIV/AIDS), cotton balls, a blade, tie string, and

disinfectant. Mama Msena kept her medicinal remedies in the courtyard, where she also

had a variety of herbs, and medicinal plants. She was petite, quick witted and full of

humor. Many women in the neighborhoods across Mombasa mentioned her name as I

conducted interviews. Mama Msena lived on the outskirts of Mombasa, but women came

to see her for different ailments, particularly infertility. Women stated that they respected

her because of confidentiality and generosity. Women came in for massage therapy,

particularly after delivery, and interviews were conducted after their visits in the

courtyard or by following women to their homes.

Women went to Bi Zuena for different reasons. She had worked in a hospital as a

clerk, before becoming a traditional birth attendant (TBA). She did not indulge in herbal

healing, although she performed massages. She stated that she was conducting less

childbirth deliveries with the intention to discontinue the practice. One of the main

differences between these homes and the biomedical facilities were the one-on-one

rapport between care-giver and patient. About thirty percent of women in this study used

home-based maternity services. From my interviews with these women, they understood

the dangers that this choice involved, should an emergency arise during delivery, but they

chose to overlook those dangers. I will revisit this issue in Chapter 6. Some women who

could afford the other biomedical facilities still attended the services of the TBA and

other healers for home remedies and massage therapy.









Traditional Healers: I reached the Maj engo market as directed to meet Bi Riziki,

a healer. I had been informed she had expertise in treating problems associated with

pregnancy. After crossing rainwater-fi11ed potholes on the path, and dodging human and

automobile traffic, I arrived at the entrance to the market. I asked for Bi Riziki and was

directed to her stall. She was standing by a shelf filled with a variety of herbs, roots and

some form of vegetation. Her son and also assistant was welcoming, but she looked at me

suspiciously, particularly when she saw I had a tape-recorder and camera. I assured her

that I was not going to use them without her permission. She relaxed temporarily, but was

on guard throughout this initial visit. I refrained from asking her or her clients questions

and instead observed their activities. On future visits, she calmed down, and I was able to

interview her and some of her female clients. She even allowed me to audio tape her and

take pictures, something I had not been able to do throughout this study. Women came to

Bi Riziki with complaints of gynecological and obstetrical problems. At times, she

walked away with them from the stall, for privacy, something that I also imitated when I

interviewed one of her female clients. Women also brought their partners and infants for

consultation.

The second healer Bi ZamZam was from a different ethnic group from Bi Riziki.

She was more relaxed, and had no reservation in explaining her different types of

remedies. Women came to her mostly for treatment of anemia and for massage therapy.

She referred some of her patients to Bi Riziki and the hospitals when the ailments were

beyond her scope of treatment.

Home visits "Are you an American spy?": Conducting home visits was the

most difficult part of the data collection. I initially wanted to interview women in their









last month of pregnancy and do a follow up visit after they delivered. This proved to be

impossible because most women (especially those unemployed) moved to their mother' s

or in-laws' house for the forty days after delivery. This is a cultural practice called

arubaini (forty days) to help the mother and baby recuperate after the strain of labor. The

woman is considered unclean after childbirth, and is excused from household duties, until

after the forty days. The practice of arubaini varies in Mombasa' s different ethnicities

and economic status. I will return to this issue and how it affects the use of health care

services in Chapter 3.

To find women whom I might interview in their homes, I walked door to door

through the neighborhoods mentioned in Figure 4. 1 to inquire if there were any women in

arubaini. These neighborhoods are densely populated, with houses very close to one

another, and people are involved in each other's affairs. This made it easy to find mothers

in arubaini. On the other hand, home visits were time consuming, because it was difficult

to enter and exit immediately after an interview. Some people wanted to get to know me

and my work, and asked about life in America. I developed a short and uninteresting

narrative that I kept repeating and that would not prolong my stay. Most of the homes

consisted of extended families or had visitors to see the mother and new baby. One-to-

one interviews were difficult to conduct, with a lot of chit-chat before and during the

interview I avoided late evenings in order not to interrupt meal and family times. I also

excused myself when partners arrived home. I did this for two reasons. First, I understood

the culturally appropriate gender roles. Women are expected to cater to their partners

when the latter arrive home. Second, while I encountered few men during this study,

those whom I did meet were suspicious and questioned me about my research,










particularly when I mentioned that I was associated with a university in the United States.

This suspicion from men made the women uncomfortable and I knew that under these

circumstances, their answers to my questions would be inhibited.

The suspicion among men reflected anti-America sentiments in Mombasa. The

American invasion of Iraq started in March 2003 and I started home visits in August of

the same year. Various groups of Muslims in Mombasa, particularly young men, had

demonstrated against American involvement in Iraq. There was plausible suspicion that

some Muslims were involved in the Al Qaeda movement, which resulted in a joint effort

by American and Kenyan intelligence services to search Muslim homes in Mombasa.

This created an ambience of distrust and I was at times asked by men, during my home

visits: "are you an American spy?" or "how do we know that you were not sent to

investigate about terrorism?" The women did not question me, but once their partner had

created an air of distrust, women became wary and their answers to questions became

cautious. Warren and Hackney (2000: 17-19) observe that anthropologists have been

considered as spies from the United States government everywhere they have done

ethnography. They add, however, that men are more likely to be suspected of being spies

and indeed, in Mombasa I felt I was regarded with less mistrust because I was a woman.

Being a woman, I was perceived as having less power, and therefore not dangerous.

These interviews of Muslim women in Mombasa about their pregnancies and

childbirth experiences were, at times, cathartic. I found it hard to remain uninvolved,

emotionally, and to focus on data collection, but I did not let the need for obj activity stop

me from answering questions from my informants or assisting them with information

about women's or infant' s health, care of infants, breast feeding, mixed feeding, and so










on. Women disclosed their health problems to me and I provided advice within the scope

of my knowledge as a nurse practitioner. Some of my advice was practical, such as how

to position infants and prevent nipple soreness or breast engorgement. At times my

advice turned out to be impractical. For example, I counseled women to use canned infant

formula instead of diluting cow milk for feeding newborns. I later learned the difference

in cost. My twenty years' experience as a nurse and midwife helped me establish strong

rapport with my informants. There was a cost to this, as well as a benefit, for with that

rapport I heard many stories of pain and suffering.

Statistical methods

The data from the 265 structured and semi-structured interviews were analyzed

using SAS and SPSS. The questionnaires and codebooks for the structured interviews are

in Appendix 1.

There are two dependent variables in this study, both of which involve the use of

maternity health care services. One is the use of prenatal care and the other is choice of a

birthing center. Since the dependent variables are binary, I used a logistic regression

model to estimate the probability of women' s behavioral choices, given a series of

independent variables.

The narrative data were analyzed with the help of Atlas/ti (scientific software -

version 4. 1). Analysis of women' s narratives about their use of maternity health provides

insight not obtained from the quantitative analysis.















CHAPTER 5
RESULTS FROM THE DATA ANALYSIS

Introduction

This chapter presents selected results from the structured interviews. The individual

respondent' s questionnaires provided information on the following: socio-demographic

characteristics, household characteristics, knowledge of mother-to-child HIV

transmission, and the seeking/utilizing of maternity health care. In answering the

question, "what factors impede or provide access to maternity health care?" I created a

number of variables, guided by the literature, about how women make health care

decisions. Any individual decision can be driven by more than one factor. For example, a

woman might have health care insurance (which would allow her to deliver at a hospital

at no cost), but decide to deliver at a home-based maternity facility for some personal

reason (like not wanting to be probed clinically by strangers

Analysis

Since the two dependent variables are binary, I apply logistic regression. (Logistic

regression estimates the probability that the qualitative dependent variable has two

possible outcomes [Allison 1999:19, Agresti and Finlay 1997:575]).

The dependent variables are:

1. Did the informant get prenatal care (yes/no)
2. Did the informant use a birthing center (yes/no)

I used stepwise selection to determine the final list of explanatory variables in each

model. Considering the sample size, I included variables that were significant up to the










0. 1 level. The results of this exploration for the two models are shown in Tables 5-5 and

5-6.

In Model 1 (Table A-5) the informant attributes with statistical significance are

education, partner' s Islamic education, telephone ownership, knowledge of HIV

transmission (in utero) and number of miscarriages.

In Model 2 (Table A-6) informant attributes with statistical significance are ethnicity,

health care insurance, respondent' s education, test for HIV, knowledge of MTCT(in

utero), previous childbirth, education and HIV test and previous childbirth and HIV test.

The reasons explored for using prenatal care or for a particular birthing center

were: the fact that the institution followed Islamic practice, distance, the presence of

health care providers, cost, the presence of services and a woman's particular health

problems. Tables A-5 and A-6 show the p-values and odds ratios for the nature and

strength of association between the dependent and these explanatory variables. In Model

1 explanatory variables with statistical significance were distance and health care

services. In Model 2, distance, health care providers and cost had statistical significance.

Section A Socio Demographic Characteristics

Age: As indicated in Table A-1, the respondent's ages averaged 26, with a range

of 16-47 years. Across the world, women younger than 20 or older than 35 experience

more obstetrical complications than do women between 24 and 34. Although not

statistically significant, younger women in my sample use health care services less,

particularly with their first pregnancy, although more deliver in a biomedical facility. As

well, lower socioeconomic status and lack of social support mean that younger women

have less access to health care than older women. On the other hand, women who have

more than two children use prenatal care less and take time before going to a facility to










give birth if they do decide to go at all. This relaxed attitude stems from experience of

previous childbirths.

Ethnicity: The largest ethnic group in Mombasa is the Mijikenda, who comprise

30% of my sample (N=80). The second largest group in my sample, at 27% (N=70) are

self-identified Arabs. Only 5% (N=14) stated they were Waswahili. Ethnic affiliation is

fluid in Kenya "situational, rational and changeable," as Cooper (2000:120) says. This

has long created confusion in Kenya, particularly during census collection ((Republic of

Kenya: Census 2001). For example, people of the East African coast, particularly those of

mixed ancestry such as Arab/African or Asian/African, are all identified as the Waswahili

by the Kenyan government (Middleton 1992). However, women categorize themselves

differently from how they are labeled. Ethnicity does not play a role in seeking prenatal

care (Model 1) but it plays a very significant role (p< 0.0001) in the choice of a birthing

facility (Model 2). There was higher probability that Arabs, Asians and some Waswahili

will choose biomedical childbirth facilities than the other ethnicities because of

affordability (OR= 12.17) (Table A-6). Marginalized ethnic groups use health care

differently from the dominant groups in societies. In observation as well, childbirth

assistance by a TBA was more common among the Mijikenda, Bajuni, Jomvu, and

Changamwe. In Mombasa, historically, the Arabs, Asians and some Swahilis, have had

resources deprived of the Mijikenda and other smaller groups (Mkangi 1995). This has

been shown as well in various other studies outside Africa, for example in Britain, Petrou

and colleagues (2001) infer that women of Pakistani and Indian origin made fewer

prenatal care visits than white British women. This above study claims cultural and

religious beliefs as plausible factors to decreased attendance. Similar studies in the









United States have indicated that African-American, Mexican-American and Puerto-

Rican women do not adequately use maternity health care (Echavarria and Parker 2001,

Gardener et al 1996, McCaw-Binns et al 1995, Lia-Hoagberg et al 1990, Petitti et al

1990). These studies stated that socio-economic status plays a role in access to health

care services leading to poor maternal/child health outcomes.


Education: Respondent' s education is highly significant in both models, use of

prenatal care (p=.001) and in choice of childbirth center (p=.02). There is a high

correlation between education and better health care. On evaluating respondent' s

education, about (N=3 1) 12% of women had never been to school (see Figure A-2).

Reasons for not attending school varied, the most consistent was inability to afford

schooling. Although school attendance had been free for this population, parents still had

to pay for uniforms and school supplies. The above 12% estimate of Mombasa Island

alone was slightly higher than the whole district' s estimate which was 8%. However, it is

lower in comparison to the country's estimate which is 3 5% (Republic of Kenya: Census

2001). More than half of the respondents (N=142) 54% had elementary or primary

education. The numbers decreased with secondary education to (N=89) 34% and only

two women had a college degree.

The probability of use of a biomedical facility increases when the woman or

spouse have higher education and subsequently increased socioeconomic status. The odds

of using a biomedical facility increased as women' s educational level increased (OR =

0. 11) (Table A-5) and (OR=0.01) (Table A-6). Although education was a factor another

component that was obvious on observation was respondent' s economic status.

According to literature, women's access to resources, including health care increases as









their personal socioeconomic status rises independent of their spouses and children

(Handwerker 1989). Assessing women's socioeconomic status was difficult because

women downplayed what they did both in trade schools as well as outside the home.

More than half of the respondents (N=139) 53% stated that they were "only" housewives.

Nevertheless, I observed the maj ority of women involved in many different home-based

trades. These j obs consisted of selling j ewelry, cloth material, fried potatoes, frozen

lollipops, and even selling water. Some women claimed that they were in sales, (N=56)

21%, they sold items door to door or to shopkeepers.

Islamic education: In Mombasa, Islamic education is started before secular

education and is not entirely free. Only 17 of the women (6%) had no Islamic schooling.

These few women were either recent converts or had parents who could not afford the

cost of Islamic education. Muslim clerics charge about 50-200 Kenyan shillings (about

one to three U. S. dollars) per month to teach Quranic classes. Sixty-three of the 146

women who had completed grade school said that they were continuing their education.

Women in this group also reported meeting with others for other non-religious

discussions, such as issues involving the community, health, education and politics.

Several of the women in this group were educators, conducting classes from home or

involved with madrasa~s.

Islamic education was not statistically significant in either of the two models.

Marital status and union: The overwhelming majority of the respondents were

married (N=257, 97%). Women who reported being separated or divorced stated that the

breakup of their marriage had occurred while they were pregnant. There was only one

unmarried woman and two women cohabiting under a common law relationship. Five









women stated that they had left their marital homes to go to their parents' homes after

childbirth and had not gone back.

Among those married, approximately 87% (228) stated they were in a

monogamous relationship, while about 11% (29) reported being in a polygynous

relationship. Some women in polygynous unions stated that their husbands alternated

households, dividing his days among the wives. This could, they reported, change in late

pregnancy, where the husband had to be available in case the wife went into labor. Only

one respondent stated she delivered at home, having been delayed in going to the hospital

while waiting for the husband to return from the other wife' s home The maj ority of the

respondents were married (N=257) 97%. There was only one unmarried and two

cohabiting under common law relationship. Women, who declared separation or

divorced, stated that the separation or divorce had occurred while they were pregnant or

during their postpartum period. Five women stated that they left their marital homes to go

to their parents' homes after childbirth and have not gone back.

Section B Household Characteristics

Health care advocates: According to the health care access literature as discussed

in Chapter 1, support from spouse, family or friends plays a role in how women use

biomedical health care. In this study, women's supporters and social network was

assessed through investigation of the household characteristics (see Table A-2).

Spouse's education: Men had more formal education than did their partners.

Male partners without formal education were (N=4) 2%, and elementary education was

about (N=85) 32%. The numbers with a secondary education were (N=153) 58%, and

(N=11) 4% had a college degree. Trade schools were attended during and/or after

secondary schooling. Although spouse's secular education did not have statistical










significance in the logistic regression models, educated men were more supportive of

their wife' s use of biomedical health care (OR=0.23).

Partners with an Islamic education encouraged their wives more to use biomedical

prenatal care (p=.07). Spouses with secondary secular education also had advanced

Islamic schooling.



Spouse's occupation: Partner's education and occupation played an important

role in affordability of health care. Approximately (N=66) 25% of the respondent' s

spouses were drivers. Drivers in Mombasa operate private public transportation or vans

called matatus. The matatus transport commuters within the island for a minimal amount.

Other drivers moreover, transported goods from the island inland to other parts of Kenya,

or to other countries, such as Uganda and Congo. Approximately 35% of partners work

out of the country, and visit their wives in Mombasa after a few months, a year or even

after two years. Their wives stated that these visits lasted a month or two. Researchers at

the Coast General Hospital reported that, they had observed that the maj ority of their HIV

positive women had spouses who were drivers, both local and long distance. Extensive

research on the spread of HIV among truck drivers has been conducted in Africa. These

studies explain men's high risk sexual behaviors with prostitutes at truck stops to and

from their destinations (Rakwar et al. 1999, Nzyuko et al. 1997).

Other occupations included clerical office workers (N=46) 17%. Involvement in the

local tourism business, either on a full-time or part-time basis was explained as a maj or

source of income. Odd jobs to supplement income were explained as a survival approach

needed at a time of inflation and a poor economy.










Adults in the household: The number of people in the household played a role in

the acquisition of health care. The maj ority of the respondents lived in nuclear

households (N=169, 64%). About a third (N=87, 33 %,) had in their households three or

more family members that is extended family. In the survey there were some respondents

who reported living with sharing the household with many in-laws, up to four brothers-

in-laws and their wives. Advice and decisions about health care in such households was

complicated. As stated by one respondent, "I ask my husband where to go for prenatal

care; however my fellow sisters-in-law also help me make decisions. But our mother-in-

law has to approve before a final decision is made"

More than half of the respondents (N=136, 5 1%) stated they consulted their

husbands on when or where to initiate prenatal care and choice of a birthing center. A

few (N=39, 15%) made their own decisions, while the remainder consulted their mothers,

in-laws, or friends.

Women who lived with their in-laws stated that they felt obligated to seek advice

from their in-laws before making final decisions concerning health care. One respondent

said, "after all I now live with them, they are like my parents. I have to include them in

all decisions".

On a few occasions, women complained that their mother or sister-in-laws were not

as sympathetic as their own female kin. One informant protested, "My mother-in-law left

me in labor for two days before my mother came to escort me to the hospital". I observed

that a maj ority of women' s mothers were involved in caring for their daughters while in

labor and after childbirth, nonetheless the husband and his family had the final word on

deci sions.









Medical Insurance: Respondent's with medical insurance comprised a quarter

of the participants (N=69 26%). Availability of insurance had marked statistical

significance (p = .0008) in Model 2. Women with higher income (whether their own or

from spouse/family) were more likely to have medical coverage than were those with

lower incomes. Medically insured women had access to biomedical prenatal care

facilities and could afford to deliver at hospitals (OR=0.28). Even so, a few such

respondents complained that they did not use private hospitals. Some said that the

maj ority of the hospitals demanded user fees before rendering services. The government

run national hospital insurance fund (NHIF) was not trusted by many hospital

accountants and physicians for timely reimbursement. Respondents also asserted that the

NHIF and other insurance companies took too much time to reimburse them. Employer

sponsored private health insurance for workers were one of the primary sources of

coverage. Among the private sector firms, employers that offered insurance had varying

premiums by industry. Respondent' s reported that the maj ority of the employers of many

firms either did not offer or could not afford to contribute to the premiums. Most of the

uninsured did not have regular doctors, and moved from provider to provider in search of

affordable health care.

Water availability: Mombasa suffers many of the problems one finds in most

third world cities. The town's growth preceded the establishment of a solid, diversified

economic base to support housing and other infrastructure. Piped water, electricity and

sanitation are still inadequate and women spend a lot of their time getting water for daily

use. Although water was not statistically significant in Model 2, it was a maj or

component in health care and a time-consuming commodity when not easily available.









Unsafe water carries diseases, including typhoid, cholera, hepatitis, dysentery, amoebiasis

and intestinal protozoa. Approximately one-third of the respondents had complained of

suffering from typhoid while pregnant. I will discuss this issue further in the next chapter.

Electricity: The vast maj ority of the respondents (N=244, 92%) affirmed having

electricity. Power outages, however, are common in order to conserve fuel. For people

who have wells and water pumps, lack of electricity meant lack of power to extract water.

Women had to time the availability of electricity so that they could be home to fill water

into buckets or plastic cylindrical bins for later use. At times the period of no water or

electricity was announced on the radio, at times not. I observed quite a few births when

there was no electricity; attendants used kerosene lamps, flash lights or candles.

The approximate eight percent who stated they did not have electricity had

complaints about the power and lighting company not being efficient in reconnecting

electricity after disconnection.

Car ownership: Thirty-three (12.5%) women stated they had a car, but cars (or

lack of it) were important for all women when they needed to go to the hospital in a

hurry. A couple of home births occurred due to lack of transportation to take a woman to

the hospital. Car possession whether private or of companies were requested to transport

neighbors and friends to and from the hospital. Doing favors to transport the sick to

hospital was an everyday occurrence.

Telephone ownership: In the questionnaire, (N=175, 66%) of women reported

they had mobile telephones. Telephone ownership was a significant (p= .01) predictor of

a woman's using prenatal care services (OR=0.16). Some women stated they would

rather be without other household necessities but have enough minutes on their phones.









Even street vendors who could barely read or write had mobile phones. A few

interviewees who reported not having a phone stated that their husband or other family

member in the household had one.

Respondents with phones used them to inquire about health care providers and

services from others who have been to them. Some women reported going to a clinic and

being told to return another day because the blood pressure machine or the hemoglobin

testing instrument was not working. Women who had mobile phones said that they would

call ahead and make sure that there was a physician on duty or that certain services coulld

be performed. Telephone possession also increased convenience in making arrangeme

with relatives, friends or business acquaintances, providing time to attend the clinic fo

prenatal care. Mobile phones are not cheap. However, as the numbers indicate, women

value their phones greatly.

Section C Knowledge of Mother-to-Child HIV Transmission (MTCT)

The Kenyan government in conjunction with world health bodies has done maj or

campaigns to promote HIV/AIDS prevention and transmission. The vast maj ority of

respondents (N=249, 94%) stated their awareness of MTCT. Less than five percent

acknowledged being uncertain of modes of transmission, while less than two percent

declared being completely unaware (see Table A-3).

Also, the vast maj ority of women (N=245, 93%) (Figure A-3) confirmed that the

media was their main source of information. While conducting this study, I heard daily

public service announcements about HIV transmission, informing the public on the

importance of prenatal care and the possibility of MTCT. Information about HIV/AIDS

was also present in the newspapers almost daily.









Women could check more than one source of information for this question and

health care providers were listed by 113 respondents (43%). Various clinics held teaching

sessions with prenatal care attendees and informed them about MTCT. Posters were

evident in almost all clinics and hospitals.

In addition, women aged 16-25 reported getting information about HIV

transmission from schools. A few of these respondents stated that they belonged to

HIV/AIDS advocacy groups initiated from high school.

Only 41 women (16%) acknowledged open or informal discussions about HIV

awareness, let alone MTCT. Indeed, open discussions about HIV spread and preve

were never without reservations--such is the stigma and shame attached to the dis.

Many women who are aware of MTCT are aware all three modes of transmission: in

utero (N=207, 78%), during childbirth (N=185, 70%) and while breastfeeding (N=160.

60%). Women's response regarding MTCT in utero was significant (p=.03) in Model 1.

Similarly, in Model 2, (p=.0001) the probability of a woman attending or delivering in a

biomedical birthing center increased if aware that she was HIV positive (OR=0. 19)(Table

A-5) and (OR=0.22)(Table A-6). Though radio messages educated the public on the

importance of prenatal care and HIV testing while pregnant, the messages were not

specific about the three modes of transmission. Respondents may have been aware of

transmission during childbirth, but they did not say that it was important enough for them

to deliver in a level 2 or 3 hospital where there can be MTCT prevention.

Prenatal HIV testing: Prenatal HIV testing and screening has been

recommended for every pregnant woman by the World Health Organization. Over 70%

of respondents reported being tested for HIV were (N=189). HIV testing was highly










significant (p=.01) in the model for choice of a birthing center. The combination of

increased education and having been tested for HIV is significant in the model (p=.03)

(OR=1.11). That is, women who had increased secular education and had an HIV test

chose a biomedical birthing center.

In this study there was no confirmation whether those tested went back for results,

or whether the results were positive or negative. However, according to the literature, and

from my own observation, the maj ority of women tested for HIV do not go back for

results. In addition, lack of follow-through, particularly in a poorly established health

care infrastructure, leads to lack of counseling, diagnosis, and treatment for those how are

HIV-positive. This was evident in both the clinics and hospitals in Mombasa.

Obstetrical Characteristics

Number of children or parity: Previous childbirth experiences both good and

bad played a role in how women accessed maternity health care. Women with previous

childbirth formed the maj ority of the respondents at (N=166) 63%. There was marked

significance (p=.0001) in previous childbirth and choice of a birthing center, but not in

use of a prenatal care facility. First time mothers, plus women who have had more than

Hyve pregnancies are associated with using non-biomedical facilities (OR=0.29). First

time mothers mostly belong in the younger age group of 16-25, have lower

socioeconomic status, and at times lack the skills in dealing with health care providers. I

observed that the experienced mothers utilized social support more from their families

and the community, and had more experience in dealing with health care providers.









The combination of previous childbirth and HIV testing had a marked statistical

significance (p=.0009) in Model 2 demonstrating that the probability of a multigravida

who had had an HIV test delivering in a biomedical facility increased (OR=2.98).

Number of miscarriages and/ or stillborn: Women who had experienced bad

obstetrical outcomes in a previous pregnancy or pregnancies utilized maternity health

care early and frequently. This has also been documented by Ivanov and Flynn (1999)

their study of bad obstetrical experiences and use of prenatal care. Approximately (N=3 5)

13% of respondents had had one or more miscarriages. Most of these respondents had up

to 14-16 visits, compared to the average of seven (OR=0.58). Fear of losing another fetus

prompted women to seek prenatal health care more consistently after a previous bad

outcome (p=.03). Women, who had a stillborn and had not attended prenatal care, blamed

themselves for the loss, stating that they understood that a biomedical facility could have

provided other options of care.

Section D Utilization of Maternity Health Care Services

Prenatal care utilization: As is often the case in developing countries most of the

women in this study initiated prenatal care well into their pregnancy--after the fourth

month of gestation (Figure A-4). Despite this, 68.3% of them (N=181) (Figure A-5) had

more than six visits, which is considered adequate in most circumstances, (N=20, 7.5%)

had exactly six visits. Still, 21.5% (57) had less than six visits were and 2.6% (N=7) had

no visits. Reasons for inadequate or no attendance included lack of money to pay for

services, not having childcare, or simply not having problems with the pregnancy. To

further investigate causes that assist or impede the use of health care services, I










questioned women whom they consulted for advice in making maternity health care

deci sions.

Advisors: Informal advisors play an integral role in health care across the world

(McKinlay 1973, Janzen 1978, Feierman 1981). Over half (N=136) of the women

reported that they consulted their husband in deciding on whether to initiate prenatal care,

especially if money was needed to pay for the services or if permission was needed to

leave the household. Husbands were also consulted if they knew about health care

providers or could provide transportation.

Other family members were consulted, particularly when there were complications

to the mother or the baby, or if women needed help with hospital costs. Consultations,

however, could have bad outcomes. One woman reported that she had had prolonged

labor, and that the obstetrician had told her and the family that she had a big baby and a

narrow pelvis, requiring a cesarean section. The husband consulted with his mother and

mother-in-law to decide about surgery. They disagreed about it, and while they discussed

it, the child was stillborn.

Choice of a childbirth delivery center

There were five areas itemized in this study of where women chose to deliver their

babies (Figure A-6). These are:

1. Home with no assistance
2. Home with a traditional birth attendant (TBA)
3. Home with a clinician (nurse/midwife/physician assistant)
4. Level 1 biomedical facility (these levels are explained in detail in chapter 3)
5. Level 2 biomedical facility
6. Level 3 biomedical facility

Starting with the top levels which are 2 and 3, these hospitals were equipped with

urgent care services to care for both mother and baby. These hospitals had the capacity










among others, to care for an HIV positive mother and prevent MTCT to the baby.

Respondents who had attended such facilities were (N=118) 45%.

The level 1 hospital was almost similar to a woman delivering at home with a

clinician. Approximately (N=1 10) 42% of respondents used this facility, which dic

have the capability to prevent MTCT or mortality. During the interviews, the clinic

level 1 centers stated that they referred women with complications (HIV positive patients

included) to the level 2 or 3 hospitals. However, they sometimes received referred

women because they complained of hospital costs. In the next section, I will explain a

woman's other reasons for choosing health care facilities.

Some respondents, (N=34) 13% asserted preference of a home environment for

childbirth, with a traditional birth attendant (TBA). Most neighborhoods had a TBA or

were close to a clinic where medical personnel were at times called to assist with a

delivery .

Reasons for using a facility for prenatal care or childbirth

Islamic medical institutions: Women had many reasons for choosing a facility. I

asked women to choose the five main reasons for why they would go to a particular

facility. The most commonly repeated reasons were itemized 1 to 5, (Table A-4) number

one being their most important reason, while five being the least.

Since this study was conducted within the Muslim community, I expected the

maj ority would prefer an Islamic run medical institution. I included this assertion as one

of my hypothesis. As stated earlier, only (N=3 1) 12% stated that they would make

religion as a deciding factor, there was no statistical significance in both models. Support

of an Islamic establishment or muungano wa Waislamnu (Islamic solidarity) was not a

reason of using a facility. The three Muslim run hospitals were built with the intention










of providing access to appropriate health care to those poor Muslims who could not

afford the private hospitals, and also as an alternative to government run hospital

Women often complained about their dissatisfaction with the above institutions wl

were mainly due to mismanagement and cost of attending them. Respondents who Ysltate

using Muslim-run facilities agreed that they used them for tohar or hygienic cleanliness.

Another factor named was stara, although this can simply be translated as the upholding

of one' s respect and virtue, the context enforces a health care provider the moral and

spiritual obligation to protect and honor the individual in their care.

Distance: Distance to a clinic or hospital has been described as a main factor

hindering women from accessing health care. In an urban area like Mombasa, where

transportation and health care facilities were not far from each other, approximately

(N=83) 3 1% of respondents reported distance as a reason for using maternity care.

However, distance had a statistical significance (p=.09), with the odds increasing by 74%

that a respondent made a choice of a prenatal care facility depending on distance.

There are numerous health care facilities at close proximity around Mombasa.

Transportation with matatus (transportation vans) was constantly available at a cost of

Ksh. 10 (equivalent to a United States penny). Women did not have to travel far to receive

care, however, when I questioned some women who had traveled further away from

centers closer to home, they stated that they were in search of either better facilities,

health care providers or shopping for affordable care.

When choosing a birthing center, there was statistical significance (p=.06), with the

odds increasing to almost 78% that a woman would choose a center due to distance.









Women chose facilities for childbirth closer to their homes, in the event that they went

into labor at night, where transportation may not be available.

Health care providers: Health care providers influence women's decision of

where to go for care. Respondents affirmed that they moved to different providers

search of good care. The physical and verbal abuse of women during pregnancy at

childbirth has been documented by Allen (2002), Fon et al. (1998), Okafor and Rizzuto

(1994) and Sargent and Rawlins (1991). Interviewees who chose attendants as reason of

choosing a health care facility were (N=115) 43%. There was no statistical significance in

model 1, indicating plausible flexibility while a respondent was pregnant. However, in

choice of birthing center there was statistical significance (p=.03) with the odds highly

increasing at 82% that health care providers was a maj or factor in choosing where a

women delivered their babies.

Cost: Shopping and paying for affordable maternity health care was a struggle for

many women in this study. Although only (N=101) 38% stated that cost was a factor

while they searched for affordable prenatal care, with many acknowledging that it was a

maj or factor for choosing a childbirth facility. Most women commented, ikiwa sina pesa

sendi clinic (if I don't have money I don't go to the clinic). Payment for preventative care

was a reason used for not using services, especially when other pressing financial needs

took precedence in the home.

Almost all the women (N=99%) did not have home-births, signifying that although

cost was a factor, compromises were made to pay for services or sometimes women were

not paying for services. In choosing a birthing center there was a high probability










(p=.0001) that cost was a maj or factor, with the odds being high that a woman will

choose a birthing center depending on affordability.

To deal with payments after birth, interviewees stated that other family members

were requested to help with contributions (mchango) to help pay for childbirth costs.

Women in most hospitals were retained after postpartum discharge until the bill was p

leaving husbands to raise funds to pay before the mother and baby could be released.

Nurses reported that at times women sneaked out of the hospitals leaving their babies

behind, later to return to claim their babies after paying the hospital bill. Attendants at the

home-birthing centers complained that they had to force women to pay a deposit before

childbirth with the fear that, that would be the only payment to be received after the

woman and the baby left. The balance with some women would be given in installments,

however with some there would be none.

Health care services: The choice of health care services went hand in hand with

health care providers, With the maj ority of the respondents (N=186) 70 % agreeing that

they chose a facility according to services provided. These services included the

interaction with providers, and the efficiency of the establishment in terms of delivery of

care. Interviewees stated that waiting period to be seen by a provider was important,

availability of medication, functioning equipment and laboratory. Although maj ority of

the respondents stated these services were very important, about (N=147) 55% of them

delivered in childbirth centers that could not provide emergency life saving services for

them or their babies. Millions of women globally have babies without problems, however

when there are obstetrical complications they are immediate and require swift action.

Obstetrical emergencies that could cause maternal morbidity are hemorrhage, obstructed









labor, sepsis, and eclampsia. Since this study also assessed women's measures to prevent

mother-to-child HIV transmission, any of the 55% of respondents who might have been

HIV positive would not be in facilities that could prevent MTCT.

In both models there was no statistical significance in choice of health care services

as a reason of choosing a health care facility.

Health problems: I inquired if women chose a health care facility depending on

health problems particularly in pregnancy. The maj or health problems mentioned during

pregnancy, although some are not pregnancy related were anemia (due to diet and/or

malaria), malaria, typhoid, pregnancy induced hypertension or pre eclampsia, and vaginal

discharge (due to reproductive or sexual transmitted infections). Respondents who chose

facilities due to any of the above health problems were (N=18) 7%, plus there was no

statistical significance in both models in women's responses to how they managed any of

the above.