SW. Sci. Med. Vol. 35, No. 9, pp.

1171-1178,
Printed in Great Britain. All rights reserved

1992
Copyright 0

0277-9536192 f5.043 + 0.00

1992 Pergamon Press Ltd

CHURCH-BASED
OBSTETRIC CARE IN A YORUBA
COMMUNITY,
NIGERIA
JACOB AYODELE ADETUNJI
Graduate

Programme

Australian

in Demography,
National Centre for Development
National University, Canberra,
ACT 2601, Australia

Studies,

Abstract-The analysis of data from available delivery registers in a Yoruba community,

Nigeria suggests
that about a half of recorded births between 1983 and 1990 were delivered in faith clinics and not in
a maternity centre. This paper reports on the mode of operation of these faith clinics in the town. It was
observed that the faith clinics were under the control of mission-trained
midwives all of whom claimed
divine call as the reason for taking up the job. The midwives also listed prayer, fasting and guidance from
the Holy Spirit as their main tools of trade. They offered no medicine to their clients and would not
recommend any other treatment for them. Pregnant women that come for prenatal care are required to
attend weekly prayer meetings for expectant mothers, take weekly baths in a particular river and maintain
inward and outward cleanliness in their behaviour. The reasons for the relative success of these midwives
in the town are discussed using a combination
of economic,
symbolic interactionist
and pragmatic
approaches.
Recommendations
on how best to tap their resourcefulness
for a more effective health services
delivery in the area include making them educators on and communicators
of modern preventive health.
Key words-faith

clinics, prenatal

care, midwives,

services utilization,

The Christian Church has a historical connection

with the provision of health care facilities and promotion of better health in many parts of the developing world [l]. In much of the hinterland of Africa,
including Nigeria, missionary groups and church
organisations were the pioneers of modern health
care services and their efforts have often been successful [2, 31. The relative success of these mission health
centres compared to government centres has been
attributed to the more qualified and courteous personnel and well-stocked pharmacies in mission hospitals [4]. The current paper describes one programme
developed by an African church (the Christ Apostolic
Church or CAC) to cater for the health needs of its
members; in this case, women and their children. It
also highlights the mode of operation of this alternative source of prenatal care and its pervasiveness in
the context of a Yoruba community in Southwest
Nigeria.
Obstetric care in all its forms aims to reduce
perinatal mortality and morbidity, handle maternal
complications associated with pregnancy and childbirth, and facilitate early identification of danger
signs for an adverse pregnancy outcome to enable
prompt intervention [5]. The antenatal, intranatal
and postnatal care that occurs within church premises
and is based on the principles of faith is termed
church-based obstetrics in this paper. The term faith
clinic refers to the location (in a church premises)
where church-based care is provided.
The extent to which obstetric care succeeds in
achieving its goals is a function, inter aliu, of the
cultural, socio-economic and environmental
conditions under which the care is provided. Relatively
little is known about circumstances surrounding most

Nigeria

of the pregnancies and childbirths that occur outside

institutionalised health care centres in Nigeria, as in
other parts of Africa. While a significant proportion
of all births still occurs outside modern health care
in Africa [6, 71, many of the available studies on
maternal and perinatal mortality are based on hospital records [8-l 11. Such studies do not shed light on
the circumstances of a large proportion of child-bearing women who do not use hospitals and clinics.
Attempts to capture the socio-environmental
milieu of births outside modern health centres tend to
concentrate on traditional birth attendants (TBAs).
For example, Ityavyars study in Sokoto State,
Nigeria focused on the operations and roles of TBAs,
providing the findings that were insightful and informative [7]. Brink also reported on the birthing techniques and rituals of traditional midwives among the
Annang of Nigeria [12]. However, studies reporting
exclusively on the activities of church-based midwives
are rare. Thus, the study on faith healers in southeast
Nigeria by Uyanga [13] did not report about pregnancy care. The findings of the current study support
the observation by Maclean [14] of the growing
inthtence of the Apostolic churches on women and
child health in Nigeria. They also lend credence to the
notion that programmes that aim to improve maternal health cannot ignore the vital roles of midwives
[ 151 and community religious leaders [ 161.
Studies on pregnancy care and childbirth practices
are relevant, especially now that UNICEF is promoting a safe motherhood initiative. It has been recently
reported that the probability of an African woman
dying during pregnancy and childbirth was 1 in 21
compared to 1 in 10,000 in the United Kingdom [17].
Infection, toxemia, obstructed labour, haemorrhage

1171

JACOB AYODELE ADETUNJI

1172

and, most importantly,

abortion were reported as the
main causes of the high maternal mortality
rate.
Some studies have identified
underutilization
of
maternal health services as central to high maternal
mortality [IS, 191. In Bangladesh,
Claquin observed
that midwives delivered almost three times more
babies compared with any other category of health
practitioner
[20]. The aim of the safe motherhood
initiative to halve maternal mortality
in 10 years
seems attainable
only through improved access to
essential obstetric care and assistance by well-trained
persons in childbirth [15, p. 11. These are some of the
reasons why attention to the study of health providers
in child-birth is now being renewed [21].
THE DATA

This paper is based on a two-stage study of a

Yoruba community.
A pilot study conducted
between December
1988 and January
1989 in Efon
Alaaye. Nigeria was followed by a more intensive
survey and in-depth interviews between February and
July, 1991. One of the objectives of the study was to
assess child rearing practices in the locality. including
child health care practices and their probable consequences for mortality. A combination
of qualitative
and quantitative
approaches
to data collection was
adopted in order to harness the strengths of each
method while minimizing their weaknesses.
In the survey component of the study, 838 women
between ages 15 and 50 were interviewed from 427
randomly
selected dwelling
units. To select the
dwelling units, a map of the town was divided into 66
grid squares, out of which 11 were selected using a
table of random numbers. All houses in the selected
blocks were surveyed by female interviewers.
All
women of childbearing
age in those houses were
asked questions
on their personal
characteristics,
childbearing experience, marital status and the health
of their under-5 children in the 2 weeks preceding the
survey. In all, 604 babies were delivered in the 5 years
preceding the survey date. Tables 3 and 4 are based
on these data. In-depth interviews and observations
were carried out on 25 purposively selected respondents out of the 838 in the survey. These women were
chosen for special characteristics,
such as high parity,
a high proportion
of children dead or no experience
of child death.
As a part of the qualitative
study, a total of 5
mission-trained
midwives, 2 pastors, 5 government
nurses, a local government dispenser (pharmacy technician), 5 patent medicine store operators, a private
clinic owner and 6 male farmers were also interviewed
in depth. All in-depth interviews were conducted by
the researcher. The results presented here focus on the
church-based
maternity centres in the town.
THE STUDY AREA

Efon Alaaye is a highland

town located some
120 km North-East
of Ibadan in Southwest Nigeria.

The town was traditionally

a city-state, the sixth of
the 16 crown kingdoms of Ekiti [22]. Situated on
irregularly-raised
land almost encircled by mountain
ranges, the town occupies the highest altitude in
Ondo State. Its mountains
serve as watersheds
for
important rivers in the State [23].
The towns location offers some health advantages.
The area is well drained because the soft loamy-sandy
soil does not hold water after rainfalls. Because of the
loamy-sandy
soil and hilly terrain, the water-table is
too deep for water wells to be dug. Consequently,
there were no wells within the town and very few
mosquitos. However, the encircling mountain ridges
supplied the town with about 10 rivulets of potable
water in addition to the larger Oni river. In the
absence of urban transport service, the hilly terrain
provided unavoidable physical exercise for residents
as they trekked about their daily business, while the
high altitude provided fresh air throughout
the year.
The town had a population
of about 67,090 according to the 1963 census, which would have grown
to 150,000 in 1991, assuming an exponential growth
rate of 2.9% from 1963. Etbn people are predominantly farmers, growing crops of yams, rice. cassava.
peas, various vegetables and fruits in surrounding
rainforest. Most of these farmers had a dual pattern
of residence, sometimes living in farm dwellings and
sometimes in houses in town. In 1991. they were
spending about 3 days a week in the town.
CHRISTIANITY

AND SOCIAL

LIFE IN EFON

The Christian religion has played an important role

in the social life of the people of Efon. The first
Christian mission (the Church Missionary
Society)
came to the town in 1897, followed by the Roman
Catholic Church in 1913. A notable religious revival
occurred in the town in 1930 when Apostle Babalola
came to evangelize the area [24]. Colonial records
show that the influence of the Aludura (as this type
of African church is often called) was very pervasive
in Efon in the 1930s [25]. The current survey revealed
that about
95% of the respondents
professed
Christianity,
of whom 52% were adherents
of the
CAC, 19% were Catholic and 10% Anglican. There
were then 12 CAC churches within the town, including a cathedral. The largest river in the town, the Oni,
is believed to have been sanctified by the late apostle
in 1930. giving its water some curative powers. This
is why its water is especially recommended
by CAC
midwives for the use of their clients.
Christian churches have played very active roles in
the provision of educational
and health facilities in
the town. At the time of this study, all 9 primary and
4 of the 5 secondary schools in the town had been
founded by churches. Of these, the CAC had founded
4 primary and 2 secondary schools. The first and
larger of the two hospitals in the town was founded
in 1974 by the Catholic church. The operations of this
hospital had been moved from its original site to an

Faith and prenatal care in a Nigerian town

Table I. Health facilities in Efon Alaaye, Nigeria
(1991)
Facility

Number

Hospital
Maternity centre
Dispensary clinic
Modem private clinic
Patent medicine stores
Quack medicals
Faith clinic

I
I
3
13
IO
1

Source: Field work in Efon Alaaye (1991).

empty school building within the town to enhance

peoples access to its services. The town has a local
government maternity centre and a dispensary clinic
in addition
to seven faith clinics controlled
by
African churches.

THE ORIGIN

OF FAITH-BASED
OBSTETRIC
IN EFON ALAAYE

CARE

In Africa, child-birth is one of those life events that

usually attracts much sympathetic support, care and
the co-operation
of family members and friends.
Many societies have institutionalized
the process
through specialist care-givers, sometimes called traditional birth attendants.
Historically,
Efon Alaaye
did not have an organised guild of birth attendants.
Women during pregnancy were cared for through a
process called ideyun (literally translated as binding
up of pregnancy),
which aimed to ensure that the
bound up pregnancy
reached full term and was
safely delivered. Pregnancy
care was provided by
herbalists. Those who took care of (or bound up)
pregnancies were also called upon to assist in their
delivery (or loosening)
and would, under normal
circumstances,
be responsible for the health care of
the pregnancy outcome until late childhood.
However, if a male herbalist did the pregnancy binding, he
might not be called upon to assist the woman in the
actual act of delivery but would be consulted only if
there were difficulties or complications,
especially
with the delivery of the placenta. Older women in the
household or neighbourhood
would assist the woman
in the actual process of delivery.
The founding
of the Christ Apostolic
Church
(CAC) in 1930 marked the introduction
of another
method of pregnancy care in the town. One of the
churchs fundamental
doctrines
is faith in divine
healing. This doctrine resulted in members of the
church avoiding the use of medicines, whether traditional or modern. Thus, most women in the church
would no longer go to herbalists for pregnancy and
child care. Instead, prayers would be said and sanctified water taken in response to almost all their
health problems, including pregnancy care and childbirth. The Apostle, being a male, chose fervent and
experienced female members of the church to oversee
the pregnancy delivery processes in the church while
he, in conjunction with a committee of elders, would
be called upon to handle difficult cases by prayer.

1173

It happened that one member of the church, a

nurse, assisted in some faith-based delivery sessions.
It was noticed that, with her skills, the process was
quicker and easier. After some time, the church
sought her help in providing some deeply spiritual
and anointed women members of the church with
training to complement
their faith. Eventually, the
Christ Apostolic Church School of Midwifery was
established in a town in Oyo State under this qualified
nurse. Women who are considered to be specifically
called by God into midwifery receive formal training
in this school. At the end of their training, they return
to work in churches that are able to engage the
services of a mission midwife.
At the time of this study, there were 6 missiontrained midwives in Efon Alaaye and another one
was about to complete her training. The 5 who were
available for interview said that they were called by
God to the job and that their tools of trade included
ability to pray, fast and receive guidance from the
Holy Ghost. They were also required to have had
childbearing
experience,
and be monogamously
married. There were no strict educational qualifications required when they were trained, although now
a minimum of secondary school leaving certificate
might be required.
RESULTS

The results are presented in three parts. The first

shows the pervasiveness of faith clinics in the town,
the second describes the pregnancy-care
process and,
finally, a discussion of the reasons for the utilization
of these church-based
clinics is presented. It is important to note that the data used in Table 2 were
from delivery registers in the maternity centre and
faith clinics, while Tables 3 and 4 are based on survey
data collected during the fieldwork in the town.
Delivery registers were available in five faith clinics
and in the only maternity centre in the town. These
provided the 3229 recorded births between 1983 and
Table 2. Recorded births delivered in Efon Alaaye
maternity centre and in faith clinics between 1983
and 1990 (row percentages)
Year

Faith
clinics

1983
1984
1985
I986
1987
1988
1989
1990

78
14
55
51
41
46
52
41

Maternity
centre
22
26
45
49
53
54
48
59

Total
births (N)b
100 (341)
100 (320)
100 (450)
100 (461)
100 (452)
lOO(411)
100 (427)
100 (367)

Source: Birth registers accessible during field work in

Efon Alaaye (1991).
Records were available in only 5 of the 7 faith
clinics in the town.
Figures in parentheses are number of recorded
births.
Registration of birth is not compulsory in Nigeria.
Thus, the figures in this table represent a selfselected sample (users of maternity centre and
faith clinics only).

1174

JACOB AYODELE

Table 3. Births according to place of delivery

attendant, Efon Alaaye 198S91
Number
%

Place of delivery
Home/farm
Hospital/clinic
Faith clinic
Delivery attendant
Doctor/nurse
Midwife
Others

reported

18
43
40

107
257
240

41
44
15

244
268
92

and

of

births

Source: Survey data from field work (1991).

Note: Figures in this table are, strictly speaking, not
comparable with those in Table 2. Cell values
are based on children data collected from the
retrospective birth history.

1990 which
were examined
by the researcher
(Table 2). About half (52%) the 3229 births for which
records
were available
in Efon Alaaye, Nigeria
(Table 2) between 1983 and 1990 were delivered in 5
of these faith clinics. However, the data from delivery
registers, used in Table 2, do not provide any information about the proportion
of births that occurred
outside the maternity centre and faith clinics. To gain
a better idea of the proportion
of births occurring
outside the health centres for which records were not
available, data from the survey component
of the
study were analyzed. The survey data indicated that
between 1985 and 1991 almost an equal proportion
of births were delivered in modern hospitals and faith
clinics, while 18% were delivered at home or on the
farm (Table 3). Further analysis (Table 4) indicated
that place of delivery was significantly associated with
the age of the mother, her level of education,
her
occupation and religion. The use of faith clinics was
particularly common among women aged between 30
and 34. Younger (under age 25) and older (aged 40
and above) women tended to deliver their babies in
hospitals/clinics
rather than in the other places. A
high use of faith clinics was noticeable among women
with 6 or less years of schooling, and among farmers.
Registration

procedure

To register a pregnancy in a faith home, a client

had to produce a guarantor or surety, profess faith in
Gods word, the ability of God to handle her case and
promise to attend weekly meetings. A token registration fee of five Naira (approx 50 cents [26]) was
collected. Registration
was open to both members of
the church and non-members.
The weekly meetings
were held on Wednesdays.
The mission-trained
midwives preferred women to register their pregnancies in
the first trimester, although many women did not
register until the fifth to seventh month of pregnancy.
Late-comers
were not rejected unless they tried to
register too close to the time of delivery. The main
reason for the reluctance to accept such clients was to
protect the record of successful deliveries by not
taking women whose pregnancies they had not adequately prepared for delivery or whose case-histories
were not known.

ADETUNJI

Interviews with users of faith clinics in the town

confirmed
that many did not register in the first
trimester of their pregnancy. The main reason given
was to avoid premature announcement
of their pregnancies to the world in order to prevent the evil eye
and to escape many of the required meetings and
visits to the river Oni, which was at least 2 km away
from the clinics. Some also said that they felt healthy
and did not need any urgent attention.
Pregnancy

care in practice

On the day of the meeting, pregnant women were

expected to go very early in the morning to bathe in
the river Oni and fetch water from the river for prayer
purposes. They usually then proceeded from the river
to the church for singing, dancing,
prayers and
lectures. The lectures presented practical guide-lines
for a successful gestation. Topics that were usually
covered included:
(a) The best state of mind for an expectant

mother.

Pregnant women were taught to be happy, joyful,

avoid fighting, hatred and wrangling and sing spiritual songs. They should not say bad things about
themselves
or against others and all unholy behaviours were to be avoided. It was believed that
happy mothers would give birth to joyous children,
thieves were born by thieves and termagants were the
offspring of the cantankerous.
(6) Sex during pregnancy and when to stop. Sexual
abstinence
should begin by the fourth month of
pregnancy, lest the child be dirty at birth.

Table 4. Place of delivery and mothers background characteristics

in Efon Alaaye. 198S91 (row percentages)
Place of delivery
Mothers
characteristics

Home/
Farm

Hospital/
Clinic

Faith
Clinic

Total (N)

Mothers age
15-24
I?
25-29
20
3&34
I4
35-39
19
40-49
21
1 = 36; df = 8, sig. at P < 0.05

51
41
40
39
44

37
39
46
42
35

lOO(ll6)
lOO(ll3)
lOO(l22)
100 (98)
lOO(l28)

Education (years of schooling)

0
27
l-6
13
7-10
I8
IO
II+
x2 = 27; df = 6, sig. at P < 0.05

35
41
51
51

38
46
31
40

100 (182)
lOO(l66)
100 (82)
lOO(l54)

Occupation
Public service
3
Trading
I3
Informal skill
II
Farming
27
Others
19
x2 = 40; df = 8, sig. at P < 0.05

74
48
43
32
47

24
39
46
41
34

100 (38)
lOO(l68)
loO(l27)
100 (204)
loo (47)

Religion
Christianity
I5
43
Others
51
43
x1 = 38; df = 2, sig. at P < 0.05

42
5

100 (546)
100 (37)

Source: Survey data from field work (I 991).

(I) X*-test statistic
in the table was calculated
counts.
(2) Figures exclude missing cases.

Notes:

from

raw

Faith

and prenatal

care in a Nigerian town

(c) Precautions against familiar spirits. Pregnant

women were not to walk alone in the hot afternoon
sun or in the dark hours of the night. These were the
periods when children with demonic possession and
familiar spirits walked about seeking persons who
could give birth to them. A pregnant woman was very
vulnerable, as these spirits could drive out the spirit
of the original embryo and then occupy the womb.
When born, the spirits become abiku (repeater spirits
or children who are born only to die soon afterwards
in order to be re-born in the next pregnancy).
(d) Work habits. The women were advised to avoid
work that involved bending down for long periods,
head porterage and lifting of heavy objects, as well as
leaping and jumping. Bending down for long periods
was considered particularly bad for the unborn child
as it would force dirty water in the womb into its
mouth and nose. Leaping over a ditch could frighten
the unborn child and cause the child to suffer frequent convulsive fits later in life.
(e) Health habits and hygiene. They should have
regular daily baths, wear clean loose clothes, eat good
food (avoiding stale pounded yam), and sleep in
well-ventilated
rooms. After the lectures and prayer,
pregnancy tests were conducted on alternate weeks.
These involved monitoring
the heart-beat
of the
foetus and taking the pulse of the mother. Where the
foetus had irregular heart-beats,
the mothers were
advised to stay in the mission home for some time for
soaking (serious) prayers.
During the weekly meetings, preventive (immunizing) prayers were usually offered for mothers to ward
off any form of disease either to the unborn children
or their mothers. Named diseases were knocked out
one by one in the group prayers. Apart from preventive prayers, special curative prayers to heal the sick
were also available to people who fell ill during the
course of the pregnancy.
These prayers replaced
hospital immunization
for some mothers although
some still went (albeit secretly) to receive formal
prenatal hospital immunization.
The delivery process
Delivery was also conducted through a series of
intercessory
prayers said by the midwife for the
expectant mother and her about-to-be-born
child. In
such prayers, powers of darkness were bound and the
hosts of heaven invited to facilitate a safe delivery.
One midwife interviewed, aged 56 with about 11 years
experience on the job, gave the following account of
what happens:

. if she is in labour, she will be taken to labour room where

she will be prayed for. Then, we lay the stretcher with clean
clothes and she will lie on it. If the child is coming, she will
be asked to hold to a pole and breathe or heave sighs. If the
head of the child comes out, we will start to pray that God
should help us. When the child is delivered, we use an
instrument
to take out the placenta.

What would they do if the placenta was late in

coming out? One of the midwives, aged 39 with 6

years experience
count:

on the job gave the following

1175
ac-

If the placenta is delayed, we continue to pray. We might ask

the woman to knee1 down and heave sighs, or we press her
upper abdomen, We sing songs of praise to God for helping
us even though we are yet to see it physically. Then, the
placenta will come out including the ogegere [27]. We then
return to the newborn and clean its body with tepid olive oil
and a pad. The nostril and the cord are cleaned also. We
allow the child to breathe very well before the cord is cut
with very clean instruments.
The newborn is not bathed in
water until much later, some on the second day.
2 hr after birth, Glucose D was mixed with
clean water and given to the child. Breastfeeding
began only on the second day. Up to 24 hr was given
to the mother to rest after delivery, depending on the
nature and length of her labour. She would then be
allowed to have a bath and clean her nipples. If the
mother was well and her child healthy, they could be
discharged on the third day.
What happened
if there were difficulties in the
delivery process? The midwives were asked whether
they would refer women with prolonged and difficult
labour to hospitals. They all said that they had not
had difficult cases because they used prayer to cancel
such events before they could occur. It was for this
reason that they would not want to attend the
delivery of anybody who had not attended the prayer
sessions for expectant mothers; such women could
spoil their records of successful delivery.
Asked whether they gave family planning advice to
their clients, the midwives said that the only method
they recommended
was the calendar method. They
did not insist on any hard and fast rules because of
the difficulty of monitoring compliance and for fear
of causing family breakdown where husbands had no
gift of self-control.
If members used other family
planning methods, that was regarded as their own
decision and they would not be required to report it.
The midwives also counselled and offered prayers
for women with primary or secondary
infertility,
overdue or false pregnancies, and general gynaecological complaints.
In all of these cases, the same
method of treatment was offered-prayer
and fasting,
and drinking of sanctified water. It would seem that
the midwife was not only a faith obstetrician
but
also a faith gynaecologist. These services were provided free of charge.
Interviews with users indicated that the reasons for
using faith clinics included a desire to have strong,
clean and healthy pregnancy outcomes. They said
that children delivered in hospitals might be healthy
but not very clean and strong. Some mothers also
thought that in todays world, where many children
were bad (not well-behaved), perhaps starting them
with God would give them a basis for a more
reasonable God-fearing life. A child whose pregnancy
and birth took place under Gods own people would
live and grow under Gods protection and guidance.
Other reasons that were mentioned included physical
proximity and low cost. One midwife, aged 48 with

About

1176

JACOB AYODELE

18 years experience in midwifery, said that pregnant

women came to faith clinics for delivery because of
the neatness of the environment,
the speed and ease
with which delivery took place in the clinics, the good
care the midwives provided, and the smartness and
cheerfulness that they exhibited in the performance of
their duties. Another aged 56 with 11 years experience
said that children delivered by them were children of
prayer, and would be filled with the Holy Spirit from
birth.
DISCUSSION

This paper highlights the important roles played by

the Christ Apostolic
Church faith clinics in this
locality. Faith-based
midwives were well patronised
and broadly based in the town. They were also highly
respected by their clients, not only for their skills and
mature age but also for their spiritual position. One
explanation
for their popularity might be the poor
economic situation at the time and the general shortage of money which may have encouraged people to
seek consolation
in God and use cheaper health
services. This explanation
seems plausible given that
people wittingly or unwittingly count economic cost
in almost every facet of life, and that the cost of
delivering a baby in a modern health care centre was
higher (about 60 Naira) than in a faith clinic (about
15 Naira). The cost of registration,
bedding and
providing the delivery-childcare
kit [28] was lower in
faith clinics than in a modern hospital or maternity
centre. However,
even before economic
hardship
started to seriously affect the people, utilization of
church-based
pregnancy care was higher than modem
health care and the proportion
of births delivered in
the faith clinics appears to have begun to decline
around the time chat the economic problems worsened (Table 2). The apparent decline in the use of the
faith clinics must be interpreted
against the background that records were not available from all of
them. Only one user of faith centres gave an economic reason as her main reason for choosing to be
delivered there, implying that economic factors were
not predominant.
Barber [29] also found no significant difference in the socio-economic
background of
users and non-users of modern health facilities in a
rural Yoruba area in Nigeria. Survey data in the
current study indicated
that education
and occupation were significantly
associated
with place of
delivery.
From another
theoretical
perspective,
symbolic
interactionists
believe that people live in a world of
symbols which give meanings to life and provide a
basis for social interaction. People use socially shared
symbols to define stimuli and responses to them.
They act on the basis of the meanings they have
imposed
on events and objects, rather than just
reacting to external or internal stimuli. Meanings are
constructed
in the process of interaction
through a
subjective
meaningful
interpretation
of purposive

ADETUNJI

social action. Through

the mechanism
of selfinteraction, persons modify or change the definition
of their circumstances
and rehearse
alternative
courses of action in view of their probable consequences [30]. The definition of situations is based on
culturally-derived
perceptions.
Adopting
this perspective
for the current study,
pregnancy and child care are significant events (or
stimuli) in Efon that people define according
to
certain spiritual or cultural symbols. These definitions
are shared socially in the religious setting, or in the
community as a whole, and have become a blueprint
for action. To the extent that the religious tenets of
the people provide a definition and meaning upon
which they respond to events, faith is a very important explanation
for their utilization of faith clinics.
Conformity
to tenets of faith may be upheld by
diffused sanctions to which defaulting members could
be exposed to by their fellow believers. For example.
one nursing sister in a government maternity centre
the town alleged that pastors of CAC churches
usually refused to perform christening ceremonies for
children not delivered in the mission clinics. The
pastors interviewed, however, denied this allegation.
According to Uche, the sermons of independent
African churches and other syncretic sects are more
pragmatic and touch on important
issues of direct
relevance to their members compared with orthodox
churches [31]. Examples of such pragmatic programs
included revival retreats. well-publicised
healing and
miracle sessions, testimonies of people who had been
healed and social support and comradeship
to those
who were increasingly
marginahsed
by forces of
economic and social change. Commenting on the role
of traditional midwives, Uche notes that their work
is doubly important in that they employ their skills to
serve women and children and provide an alternative
source of care for those who could not afford the
services of modern hospitals [31. p. 901. The mission
midwives in the current study performed
the functions of gynaecologists
and obstetricians.
even
though their training and mode of operation differed
from those recogniscd by Western medical system.
This is similar to the role of the successful traditional
midwife in Morocco [32].
One other important explanation for the success of
the midwives in the town is that they were usually
elderly and so served as mother figures. They were
deeply religious and their interest in the clients extended beyond the mere situation of pregnancy care
and delivery. They shared a similar cosmology with
their clients, and were people in whom the clients
could confide. They could mediate in family conflicts,
visit discharged
mothers and children at home for
further prayer and any other relevant spiritual assistance [33]. Moreover, these midwives had other points
of meeting with the clients apart from the situation of
pregnancy care such as in church, home visits, and at
the market. Some of them had lived in the town for
more than ten years and had established links with

Faith and prenatal care in a Nigerian

many homes. If they met any pregnant non-members
of their churches, the midwives would endeavour to
invite them to a pregnant womens weekly meeting.
This search for clients was part of the proselytising
activities of the midwives and it enhanced commitment the same way that it did among Papua New
Guinea midwives [34]. One midwife in this study
recounted how she went in search of one of her clients
to the clients farm when she expected her to come for
delivery and she did not.
In addition,
their clients could tell them their
problems and expect sympathy, understanding
and
help. The poor could come with whatever delivery kit
they could provide and would be accepted.
The
delivery environment
was homely, not a very formal
atmosphere
like the maternity
centre. Differences
observed during visits to these centres were that all
faith clinics were built like ordinary residential houses
and the midwives lived in them; sofas were placed
inside the wards for visitors to use and the midwives
did not usually sit in the wards. In the government
maternity centre, the building was more formal and
was not a dwelling; most sofas were usually outside
because of limited space and the nurses table was in
the centre of the ward. Moreover, the government
nurses were uniformed
while the mission midwife
dressed like her clients. The atmosphere seemed more
relaxed in a faith clinic than in the maternity centre.
Parents, friends, husband, relatives and other wellwishers could come and greet the newly delivered
babies in a faith clinic without encountering
rigid
rules. They could chat and laugh without hindrance,
and be freely prayed for by the midwife in-charge
before leaving the premises. Other children of the new
mother could play around the mission home and use
extra rooms to sleep in at night if they decided to stay
with their mother. The midwife would cook for the
client if there were no helpers around. This would not
happen in a modern clinic. Moreover, the mother and
her child could stay longer in the mission homes and
be discharged
at no extra cost if their cases so
warranted.
CONCLUSION

Church-based
pregnancy
care and delivery, the
subject matter of this paper, is an example of a
situation where faith and practical skills have been
made to converge and supplement each other. The
general mode of operation of these midwives apparently has some potential lessons for similar community-based health care programmes,
especially those
concerned with the goals of safe motherhood
initiative. The trend in the ongoing discussion about the
safe motherhood
initiative highlights the role of the
midwife as the hnchpin in obstetric care, and the need
to make a more effective use of their skill is emphasised [15]. Recognising
that delivery by traditional
birth attendants is a transitional phase [35], perhaps
faith clinics are a transitional
stage between tra-

town

1177

ditional methods of health care and the modern

western system in this community.
The midwives practice of not providing any drugs
to their clients might appear inappropriate
or even
dangerous
at first sight. However, even in modem
medical practice, it is emphasised that the body itself
can usually fight off sickness with rest, good food and
perhaps simple home remedies, and that belief is a
very important factor in the healing process [36]. It
could be argued that, by mobilizing the capability of
the body to heal itself, these midwives raised the level
of resistance to simple infections, reduced the need
for drugs, and thereby costs and the risk of overmedicalization.
The conclusion of Brink [ 12, p. 18831
after studying the birthing techniques
of Annang
midwives was that they were adequate and should be
supported rather than discarded.
The church-based
midwives also emphasised
environmental hygiene as one of their cardinal principles
of health, since cleanliness was regarded as next to
godliness. This could have had a preventive effect as
it agrees with the Three Cleans rule of childbirth
(clean hands, clean surface and clean cutting tool)
advocated
by the safe motherhood
initiative [17,
p. 15861. By advising expectant mothers to be joyous,
singing and avoiding emotionally
stressful circumstances, these midwives prepared their clients to approach their labour with peaceful minds and relaxed
bodies that are more cooperative
for delivery [37].
One of the main risks involved with the use of faith
clinics was the absence of an effective referral system,
so that treatment for women needing urgent hospital
attention
may have been delayed,
jeopardising
maternal and child health. It seems the relationship
between the modern health care centre and the faith
clinics was that of competition and rivalry rather than
cooperation.
This would not work to the benefit of
their clients. To derive the maximum benefit from the
influential position of these church-based
midwives,
they could be made educators on and communicators
of modern preventive health [33]. This would fit them
into the current advocacy of the WHO for a shift of
emphasis in reproductive
health from high technology and purely clinical to more of communication
and preventive [35, p. 5; 15, p. 81. Such a shift seems
attractive under the prevailing economic climate in
many developing countries.
Moreover, the mission midwives could be encouraged to keep accurate records of births that take place
under them and to record some information
about
parity and the survival status of past births of their
clients; such records would serve as valuable sources
of data on maternal and child health. Overall, these
women apparently
were doing a good job, to the
extent that their services provided alternative delivery
facilities for pregnant women who would have delivered under unhygienic conditions at home or on the
farm. Their service also supplements
the governments health care provision efforts and could be seen
as a form of community participation.

1178

JACOB AYODELE ADETUNJI

AcknunledRements-The
author wishes to thank the following: Professor
and Mrs J. C. Caldwell, Professor
I. 0.
Orubuloye and MS C. McMurray
for their encouragement
and visits to me during my fieldwork in Nigeria; Dr D. W.
Lucas, Dr L. Corner Dr M Whittaker,
MS M. May and
Mr B. Fitzgerald for their suggestions and contributions
in
the course of preparing
this paper. I thank Dr P. K.
Strearfield
for providing
fund from the Child Survival
project of the Ford Foundation
to pay my interviewers and
some travel expenses, Mr G. Corner for making available
his dSurvey computer package to make my data entry in the
field very easy and the National Centre for Development
Studies, Australian
National
University
for lending me a
lap-top computer. I also acknowledge
the Australian
International
Development
Assistance
Bureau, Canberra
for
tartly supporting the field trip and accept full responsibility
i-,r the content of the paper.

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