Beliefs and Practices Regarding Delivery and Postpartum Maternal Morbidity in Rural Bangladesh Author(s): Elizabeth A.

Goodburn, Rukhsana Gazi, Mushtaque Chowdhury Source: Studies in Family Planning, Vol. 26, No. 1 (Jan. - Feb., 1995), pp. 22-32 Published by: Population Council Stable URL: http://www.jstor.org/stable/2138048 . Accessed: 08/04/2011 06:10
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and Beliefs Pracfices Regarding Delivery and Postpartum Maternal Morbidity in RuralBangladesh
ElizabethA. Goodburn, RukhsanaGazi, and MushtaqueChowdhury
maternal morbidities also Mostmaternal deaths in puerperium most occur the and probably than but arise that at time. Maternal morbidities much occur morefrequentlymaternal deaths, discussions to very isknown little about their magnitudecauses. study or This usesfocus-group rural women. explore experiences the of childbirth postpartum among and illness Bangladeshi health are The women's beliefs disease about causation, their of and use traditional care, exbirth The plored. significance ofthefindingsfor the trainingtraditional attendants of andfor programspostpartum isdiscussed. of care (STUDIES INFAMILYPLANNING1995;26, 1: 22-32)

illness are that estimated there 16.5episodesofserious maternal and for to related pregnancy childbirth every estideath(Datta et al., 1980).However,morerecent of rethat number acutemorbidities the matessuggest be muchhigher, manyas 67 as may latedto childbirth suchas deathin a country maternal every episodesfor et conditions Although (Koblinsky al.,1993). Bangladesh and fistulae, prosuch as pelvicsepsis,vesicovaginal in lapse maynotresult death,theymayhave serious for consequences women. socialandphysical deathsarebelievedtooccurdurAs mostmaternal so morbidities ing thepuerperium, are mostmaternal linkedto eventsoccurring at thattime, to likely arise sepsis delivery (Fauveau et al., 1988).Whereas during causesofmaterare and hemorrhage themostfrequent the may however, pattern nal deathin thepuerperium, morbidities. is notknownhow It for well be different of play practices intheetiology magreat roledelivery a for morother factors postpartum morbidities; risk A. Technical ternal M.Sc.isChief Elizabeth Goodburn, B.Ch., M.B., of countries are in communities developing bidities rural and inmaternal child the Advisor health-family planningfor unknown. on Nations Fund United Population inCambodia, secondment also largely data existon postfew ForBangladesh, published and the from Maternal Child Epidemiology London Unit, of on durexperience illness morbidity, women's partum and Medicine. Rukhsana School Hygiene Tropical of Gazi, and or ingthepuerperium, on thelocalbeliefs customs and in Research M.Sc.isMedical M.B.B.S., Officerthe focuses thedelivto on relating it.Mostoftheliterature ComEvaluation Division, Bangladesh Advancement Rural severalanthropological For studies eryitself. example, Ph.D. mittee. Mushtaque Chowdhury, isDirectorthe of beliefs of the have emphasized importance traditional Rural Research Evaluation and Division, Bangladesh Adchildbirth 1984;Maloneyet al., (Blanchet, surrounding to vancement Committee. Correspondence beaddressed should have researchers 1985).Other 1981;Aziz and Maloney, Boeung Dr.Elizabeth Goodburn, UNFPA, RuePasteur, 53, and of techniques useda variety qualitative quantitiative Phnom Cambodia. Weng Kang, Penh, Bangladesh one of thehighest has maternal mortality live ratiosin theworld,about 600 deathsper 100,000 births (UNICEF, 1993).It is one of thefewcountries where expectancy birth females shorter life at for is than that males(UNICEF,1993).Although for manyfemale deaths occur childhood, life in the expectancy females of at age fifteen stillshorter is thanthat males, of withthe causes excessdeathsdue solelyto pregnancy-related (Fauveauetal.,1989).Themainmedical causesofthese deaths (septicabortion, hemorrhage, eclampsia,obin and infection) beendocumented have structed labor, in postpartum occur the the peseveral studies; majority riod (Alauddin, Fauveau al.,1988; 1986; et Chen al.,1974). et and Muchlessis known aboutthemagnitude causes than related pregnancy is known to ofserious morbidity deaths.A smallstudyin India in 1980 aboutmaternal
in Planning 22 Studies Family

toinvestigate delivery practices maybe potentially that harmful thehealth either to of mothers infants or (Bhatia, 1981; Aminand Khan,1989;Khan,1981). In countries suchas Bangladesh, where mostdelivoccur home, at eries maternal child and health programs often focus thetraining traditional attendants on of birth (TBAs),withtheaimofchanging improving and delivOne oftheobjectives TBA training, erypractices. of in addition improving to neonatal outcomes, toprevent is themajorcauses ofmaternal mortality morbidity. and Evaluations have suggested, however, thatTBA trainingmaynotbe as effective preventing in maternal deaths as had been hoped (Greenwoodet al., 1990;Jordan, 1989), theroleofTBA training preventing but in maternalmorbidity never has beenadequately evaluated. In December 1991, Research Evaluation the and DivisionoftheBangladesh RuralAdvancement Committee(BRAC),in collaboration theLondonSchoolof with and Hygiene Tropical Medicine(LSHTM),undertook a prospective studyofpostpartum morbidity itsreand lationto delivery practices. studywas carried The out in threeunions(administrative unitsof about 15,000 in people)ofa ruraldistrict central where Bangladesh, BRAC undertakes demographic surveillance. BRAC maintains residential for field-workerseach a base its in of thesethreeunions.Whencompleted June1993, in themainstudyhad coveredmorethan1,500women. Theprincipal objectives thestudy of weretodetermine and incidence illnessduring puerpethenature of the rium todefine risk and the factors morbidity, for includThe studywas ing eventsoccurring duringdelivery. also designedto investigate number methodologa of icalissuesinthis new the relatively field, including conbetweenself-reported and morbidities physisistency cal examinations. As partof thepreparation themainstudy, for fodiscussions cus-group (FGDs) wereheldduring August 1991to obtainin-depth information aboutlocal beliefs and practices and and during pregnancy delivery, morand customs the The bidity during puerperium. inforthe mationgained from FGDs was used to guide the mainstudy designand questionnaire and development of todevelopa vocabulary localterms.

vide considerable insight intotheproblems a comof in munity a rapidmanner. Although validity the the of dataobtained from FGDsis sometimes questioned when thetechnique used as the onlyresearch is tool,focus groups provide can invaluable background information forthepreparation quantitative of studies.Theyhave also been foundto be particularly helpful research for intosensitive subjects; recently, severalstudieshave used thistechnique explore to aspects maternal of mortality (Maternal Mortality Network, 1992; Adetoro al., et 1991). BRACmembers havehad considerable experience and conducting focus-group discussions, their familiaritywiththetechnique made formal training unnecessessionswereheld.The topics sary, although practice to be coveredby the FGDs were devised by a small groupofresearchers BRACand LSHTM,withadfrom an vicefrom anthropologist had extensive who experience in Bangladesh. Before questionsto be asked the werefinalized, werediscussedwiththree they groups of female BRAC healthworkers in working thestudy areatotest acceptability thequestions todisthe and of cernthelikely form theresponses. actualdiscusof The sionswerefacilitated an experienced female BRAC by research in field-worker had beenliving thestudy who area.Shewas given questions be usedintheFGDs the to inadvance was askedtotranslate and into comthem the rural dialect Bangla. of monly spoken In order obtain comprehensive a of to picture expeand mothers of riences opinions within community, the all ages, as well as TBAs,were includedin thefocus groups.The researchers thatmothers felt would talk if morefreely their of of were experiences delivery they in separate the that groupsfrom TBAs,and,similarly, if would feelless inhibited separated youngmothers the from olderwomen. Thus,three types groupwere of less of: mothdevised, composed (1) young, experienced or who ers-womenaged25years younger had had one births mothto three only;(2) older,moreexperienced ers-women olderthan25 yearswho had had fouror and and morebirths; (3) TBAs,bothtrained untrained. All of thetrained TBAs had undergone BRAC's own to TBA training, whichis similar thatused in thegovernment program. for Participants thegroupswerechosenby BRAC who field-workers residedat thefieldsites.Although were Methods was theselection notrandomized, participants sein of to lected be broadly representativethecommunity In recent has in educational interest grown theuse ofqualita- terms their of years, religion, level,and socioecotiverapid assessment were careful to status. Field-workers particularly as techniques a healthresearch nomic toolin developing the of wherefielding countries, largesur- includewomenfrom poorestsections thecomthe houses werenot inand lengthy Womenfrom richest veysmaybe difficult, expensive, (Folch- munity. Lyonand Trost, 1981;Schearer, 1981;Khanetal.,1991). vitedtoparticipate becausetheresearchers that felt their Focus-group might intimidate others. the Although particidiscussions a technique are thatcan pro- presence
1 1995 Volume 26 Number January/February 23

the reason forproblems during pregnancyand afterdelivor to related eachother from pantswerenotclosely manywere acquainted ery. The researchers had anticipated that evil spirits compound), same bari(family in whichwas unavoidable suchsmall would be mentionedin the discussions,as thesebeliefs witheach other, 1984;Maloney had been describedpreviously(Blanchet, communities. 10participants. et al., 1981),but the eagerness with which group memand eight Eachgrouphad between and partici- bers discussed themwas not expected.Many ofthepreof Sessionslasteda maximum twohours, Dis- cautionsprescribedforpregnantwomen are an attempt the during session. refreshments wereoffered pants roomin to avoid the actions of spirits.Both the TBAs and the private cussionswereheld insidea relatively and Men,olderchildren, onlook- mothersbelieved in the importanceof these proscriptheBRACcompound. during tions,although one of the TBAs mentionedthatnowasex ersofeither werenotallowedtobe present arrived, days, youngermothersoftenignoretheirelders' advice (If thediscussions. morethan10 participants weregivenrefreshments about correctbehavior during pregnancy,and, conseas was usuallythecase,they discussed quently,theyexperiencemoreproblems.Overall thereBRAC worker roomand another in another in- searchers' impressionwas that youngermotherswere The facilitator withthem.) interest topicsofgeneral to discussion anxious to takeall possible precautions avoid evil spirfor each topicor question general troduced skepticalof theirefwerenot its,while older motherswere more Discussions as probed was necessary. andthen completely differed Indeed,two oftheoldermothers areas.Thefacilita- fect. off allowedtowander intounrelated fromthe general view, remarkingthat therewere too weregiventhe to tortried ensurethatall participants that was not manyrestrictions, itis notpossibleto followthemall, to opportunity speak and thatthediscussion anyway. makesno difference precautions and thattaking vocalwomen. by dominated themost Most of the precautions against spirits involve were keptby a femaleBRAC rerecords Written theiratavoiding activitiesconsidered likelyto attract The in whodid notparticipate thediscussions. searcher tention.These activitiesinclude going outside at night and was also tape recorded, theserediscussion entire or used to checkthewritten or in the afternoon, going out with one's hair down weresubsequently cordings on the or withtheend ofone's sari trailing theground.One that were participants informed Although transcript. should mothers toldus thatpregnant Hindu oldermother werebeingtaped,theydid notappearto proceedings because in the evening or on a moonless night, up." A total not eat oncethesessionhad "warmed be inhibited that wereheldwitha total doingso upsetsRahu (a Hindu god). Otheractivities discussions ofninefocus-group include going outside duringstormsor afspirits one groupofeach typein each of attract ofabout90 women, maintopunionsofthestudyarea.The three thethree the during sesthatwereintroduced ics ofdiscussion 1. sionscanbe seeninFigure

Results

discusfocus-group covered during topics Figure1 Main 1991 sions,Bangladesh,

during and prevention aboutdiseasecausation Beliefs and pregnancy thepuerperium * Practices categories overlapping three expressed Theparticipants * Food restrictions childof ideas about disease causationin pregnancy, on * Restrictions activities times conis Disease atthese and birth, thepuerperium. * Health-care seeking

of abouttheCausesand Prevention Disease Beliefs

(2) by due sidered be mainly to (1) attack evilspirits; to of and practices experiences childbirth causes. Delivery are thekindsoffoodthat eaten;or (3) physical attendant and * Placeofdelivery birth of and of theconcepts prevention treatment illWhereas laborand delivery of * Conduct normal beand content thebalance these ideas,their nessreflect labor during laborand other problems * Prolonged to as progresses thedethem changes pregnancy tween * Delivery placenta of to Manyproblems and thence thepuerperium. livery hemorrhage * Immediate postpartum to are and thepuerperium linked events delivery during health problems and occurred during pregnancy, manyofthepro- Postpartum that * Abnormal discharge to are duringpregnancy intended ward off scriptions tears * Perineal events. untoward later and * Prolapse fistulae Evil Precautions against Spirits was or (bhut uprivhab) put by Intervention evil spirits common as of by forward members all groups themost
Planning in 24 Studies Family

* Eclampsia * Tetanus problems * Breast

tercooking withoil,because spirits said to be atare tracted thesmellofoil. by Discussionsrevealedthe widelyheld beliefthat abortions congenital and abnormalities caused by are possession evilspirits. TBA described by One how one pregnant mother had gone out in theevening pick to fruit had a miscarriage a result. womanwho and as One had experienced intrauterine deathdescribed an fetal how she had been walkingthrough bamboo grove a whenshewas touched an evilspirit causedher by that abdomento hardenand thebaby to stop growing. A (traditional healer)had been called in and told kobiraj thewomanto drink pora(water had blownover pani he after a saying prayer). had said a prayer waved He and a broom overher.Soonafter that, womanhad gone the intolaborand delivered macerated a baby,whichwas considered be a positive to signofpossession an evil by The offered traditional spirit. treatments healersreby in a flect belief thespiritual causation diseaseandusuof pani pora, reallyinvolvesongs,prayers, amulets, and strictions movement food. on or Theperiodafter delivery thought be oneofparis to ticular to in vulnerability spirits, whichis reflected the of Other practice seclusion. this precautions taken during periodinclude putting piecesofironaroundtheroom, leather nearthebed, and purifying feet putting of the the anyone entering room.Muslimwomenoften carry a pieceofironaroundwiththem between and for seven 40days after as The delivery a precaution. protective power ofiron a common is idea in Bangladesh North India and andhasbeendescribed elsewhere (Bhatia, 1981;Karonet al.,1983). Thestrength universality thebelief superand of in natural causationcontrast markedly withthemedical model of childbirth propoundedby the government health the The services, including TBAtraining program. that had training someoftheTBAparticipants received did notappeartohavealtered in their belief system any TBAsremain an significant Whilethismeansthat way. in integral partof thecommunity whichthey provide it the comservices, also callsintoquestion assumption, monin manyrural health that programs, TBAscan act for in as a force change health-related behaviors.

The focus-group participants linkeda number of foodtaboosduring pregnancy theorigins a speto of cificcondition; example,pineappleswere said to for cause abortion, coconuts and werebelievedto makea babyblind,a condition described "whiteeye."Anas other belief was thatducks'eggs maycause asthma in thebaby.Other restricted foodsmentioned weremilk, hilsha(a popularriver fish), other fish, cucumber. and The participants notedthatafter childbirth, Hindu womenare notallowedto eat anymeator fish one for month, whileMuslim womenarerestricted doing from so for sevendaysonly. Other forbidden foods after childbirth bananaswith are seeds,eggs,andleafy vegetables, especiallypumpkinleaves. Beefand hilsha fishare thought dryup themilkof a lactating to mother and may also cause shutika (postpartum diarrhea). During theperiodofseclusion, womenmaybe restricted one to ricemeala day,though are they permitted eat other to cerealsand milkduring restoftheday.A groundthe and garlic(a "hot"food)is up mixture cumin, of chili, eatenin theimmediate commonly postpartum period, to becauseitis thought helphealthe birth passage.Some mothers they notbeenallowedtotakeanyfood said had for first days, water. the few only saidthat Many women their water intake also beenrestricted this had at time. foodtaboosare often Although implicated conas to tributing poornutrition amongruralwomen, many ofthefoodstobe avoided, for are in beef, example, not, availablediet.Manyofthe fact, partofthecommonly one foodtaboosinvolvesubstituting foodforanother In it ordo notlastfor longperiodsoftime. fact, is questionable whether food taboos duringthepostpartum as periodhave as greatan impacton nutrition do endedemicfoodshortages, coupledwiththenutritional mandsoflactation.

Restrictions onPhysical Activity mentioned Falls duringpregnancy were commonly labor and as a cause of such problemsas premature and using the dheki miscarriage. Heavy lifting (riceto werealso identified activities be as husking machine) that avoided.Sex was another activity all groupmembers to Avoideddurattempted avoidduring pregnancy. and sex causingthefirst lasttrimester, was blamedfor Food Restrictions the and ingmiscarriages malformations. However, TBAs Food taboosare common and bothpregnancy during that to amidsomelaughter, itwas difficult keep stated, in thepuerperium India and Bangladesh (Rizvi,1976; menaway. and Katona-Apte, is 1977).Although specific prescribed of Resumption sexual relations onlyconsidered foodsdiffer from to proscribed To considerably after dayspostpartum. have sexualinterregion re- proper 40 one gion, itemofgeneral is "hot"foods course to agreement that that is before time believed causea foul-smellinadshouldbe avoided during and it After pregnancy encouraged ingdischarge. delivery, is also considered in theearly postpartum period(Khan,1981; Thompson, visabletodo heavy lifting towork thedheki. or on These 1983;Rea,1981). activities thought be a direct are to cause ofconditions
1995 1 26 Number January/February 25 Volume

None of thewomenwantedto go to thanbeingattributed thein- manydeliveries. to rather suchas prolapse, would all and for thehospital a delivery, they said they tervention evilspirits. of eventhough consider ill. the that It was clearfrom discussions doingso onlyifdesperately TheTBAstold to send all womenwithproblems that activi- us initially they ideas aboutwhichphysical womenhad definite that with them revealed they but be they childbirth, had thehospital, discussion tiesshouldideally avoidedafter themselves to alwaystry deal withtheproblem in activi- almost little overtheir participation these very control part, For as had to workthe andlookuponthehospital a lastresort. their ties.Ifthericehad tobe husked, they to sendthem TBAsnever that affirmed the if desired husbands sexualintercourse, they themothers dheki; their dead." The discushaveadvised rest, thehospital"untiltheyare nearly worker had tosubmit. Shoulda health betweenwhat the the wouldhavebeenunable follow instructions. sions highlighted discrepancy her to women actually did. to TBAshadbeentaught do and whatthey Care Antenatal profesdue totheTBAs' in have MostTBAtraining programs Bangladesh an ante- Thisgap mayhavebeenpartly itmay More and pride determination. realistically, sional to pregnatal carecomponent. TBAsareexpected identify fears aboutthepoorqualto alsohavehadmuch do with give community, examinethem, nantwomenin their of and thedifficulties transport services ofhospital of themadvice,and followthemup. A majority the ity involved. finance TBAs in thefocusgroupsstatedthattheyfol- and trained woman from second or third the low up a pregnant and Labor Delivery and of seekoutpreg- Conduct Normal Abnormal of Theydo notusually month pregnancy. womenadoptduring the In Bangladesh, usual position but nantwomenat thisstageofpregnancy, comeupon If or stageoflaboris upright on all fours. labor The them chancein thecommunity. TBAssaid that thefirst by to maybe encouraged walk the im- is prolonged, mother and work, tetanus they giveadviceaboutnutrition, with oil. massaged aboutorshemayhaveherabdomen for and check anemia, edema,and the munization; they actionis moredrastic If laborstilldoes not progress, that of could position thebaby.SomeTBAsclaimed they bandaround a Tying tight attendant. by and lie. taken thebirth detect twins, breechpresentations, transverse which believed preis to abovetheuterus, said that sendthe theabdomen Whencomplications they arise,they up rising again intotheabdomen, ventthebabyfrom to most theTBAssaidthat of However, mother a doctor. are on orevenstanding theabdomen, twosuchactions. ifa pregnant she womanis healthy, does notneedtogo withoil orputcoTBAsmassagethecervix Sometimes forantenatal checkups. Onlya fewsaid thatpregnant stretch a it, insidethevagina and manually month conutoil antenatal every womenshouldgo for checkups elswhere 1981). (Bhatia, that practice hasbeendescribed of on. the month pregnancy from fifth of exist TBAspurposely rupturaccounts Although said In contrast, groupsofmothers they not the did no 1968), TBAsin Ghosh, 1981; (Bhatia, The ingmembranes seekhelp from TBAs untillaborstarted. normally the doingso. Indeed, TBAssaid they reported this study care duringa normalpregnancy conceptof antenatal before end of the rupture that worry ifthemembranes to care was notfamiliar them. onlysought Theyusually the thesecondstage, vaginawillbe toodry.Thisbelief if felt or they during pregnancy they unwell thought had oil coconut intothevaginain an atto in wenttoa kobiraj leads them pour a problem, whichcase they usually it. attempttolubricate ManyoftheTBAsreported women beenimmunized had Someofthe orfakir. against tempt suchas transfor manipulation conditions inginternal as of tetanus partoftheExpanded Program ImmnunizaSomesaid they washed breeches. mentioned a pregnant that but acquain- verselie and footling tion, onewoman handsfirst. an deathas a result their tancehad experienced intrauterine told in Women thesecondstageoflaborareusually ofa tetanus others believedthata However, injection. some of the Although position. to assumea squatting is and tetanus mothers their pregnant injection good for that down they TBAsmentioned had beentaught lying babies. forwomento assume,nonehad a stillexists between content was thebestposition the Clearly, wide gulf to a instructedpatient do so. SomeTBAssaid that of and ofTBAtraining theactual practices TBAsevenaf- ever couldbe prevented applying tears pressure by perineal and ter the and training, between expectations knowledge delivery. during totheperineum ofmothers. are described potensomeofthepractices Although for massageofthevaginaand cervix, exharmful, tially and Practices Experiences Childbirth of Delivery were thattheTBAs in general ample,it was apparent and in seen as supportive participants childbirth that Place Delivery Birth and Attendant of were expectedand welbirth manyof theirinterventions that TBAsmakethe best Alltheparticipants agreed to adherence to oversee comed.It is interesting notethattheir untrained relatives attendants. Nonetheless,
in Planning 26 Studies Family

trying had prevented themfrom traditional behaviors to persuadewomento lie down duringlabor (which the manywomenfindintensifies pain), despitetheir to having beenbeentrained do so. Delivery the of Placenta durAll focus-group members exhibited greatanxiety The of ing discussion aboutthedelivery theplacenta. in also documented other anxiety was due to a belief, studies(Mitaet al., 1988),thatiftheplacentadoes not after comeoutimmediately birth, can riseinsidethe it and chokethemother. Becauseofthisbelief, abdomen the thecordis usuallycut onlyafter placentais comis pletely out.Ifthere a delayofmorethana fewminpullson thecordand simultautes,thebirth attendant down the hair neously pushesthemother's or a finger Some TBAs said mother's throat inducevomiting. to manualremoval theplacenta, of whileoththey attempt ersperform pressure. massageoruse fundal abdominal TBAshavebeentaught cutthecord to Although trained so the before placental delivery that babycanbe puttothe the afraid do so. Somegetaround to breast, areoften they problem tying cut end of thecord aroundthe by the tie birth mother's thigh. Occasionally, attendants a heavy for practices plaobject theend ofthecord.Similar to centaldeliveryare describedin otherAsian studies 1981). (Ghosh, 1968;Bhatia, againhighof delivery Thesedescriptions placental are by the of light belief systems TBAsthat notchanged TBAsmay where possible, training makeclearthat, and whatthey have learned makeattempts incorporate to model. intothetraditional intheir course training

A beliefs. reanew to incorporate ideas intotraditional TBAs had notbeen is sonableconclusion thattrained actionsto takein cases of about whatspecific taught hemorrhage.

HealthProblems Postpartum

of TheImplications Seclusion at starts delivery. (choti) periodofseclusion Theformal However,duringthe discussionsit becameapparent beginduron thattherestrictions a woman'smobility limiting part Although ofthereasonfor ingpregnancy. for at activity thattimeis fearof evil spirits, Muslim of are womentheserestrictions boundup withnotions to shameis attached a woextra consequently, purdah; of Feelings shame pregnancy. mobile during man'sbeing which typiof by maybe intensified theresponses men, Thus, pregcomments. and laughter ribald include cally wear a burka long-sleeved (a nantwomensometimes witha veil) when goingout of their coat,sometimes wearone. wouldnotnormally whereas they baris, in seclusion theperiodimmediately Women into go are becausethey conFirst, after birth tworeasons: for to vulnerable theattentions sideredto be particularly and second, time(Blanchet, 1984), at ofevilspirits that seConsequently, are impure. becausethey considered for clusionprovidesprotection bothwomenand men them. Sepawith by polluted contact whomight become of by men ration from is ensured thefeelings shamethat begin at Thesefeelings a womanexperiences thistime. and after during but pregnancy are intensified during among is strong in Belief pollution particularly delivery. for seclusion 30 to 40 days;MusImmediate Hemorrhage Postpartum Hindus,who observe but lims observeit foronlyseven days. Group members for hemorrhage, Ruhini a local term postpartum is of had an appreciation the notedthatHindususuallybuild a separate fewfocus-group temporary participants Ideas abouthow muchbleed- hut(choti whileMusof and seclusion, for danger thiscondition. ghor) delivery werevague.In thewordsofsomepar- limscommonly a kitchen theroomwherethe or ingwas toomuch use or dhekiis kept. "sometimes blood passes likea waterfall" and activities ticipants, on Restrictions foodintake a Onewoman areparticularly as fills water "is the the jar." bleeding as much during periodofseclusion. rigorous is childbirth not New mothers notallowedtodo normal that commented excessbleedingafter are housework, their actuallybad because it relievesuterinecramps.Al- and their are stayin movements restricted during a said thatsuch resomeoftheTBAsknewthat retained pieceof thechotighor.Some ofthemothers though such risk couldcausehemorrhaging, factors as placenta are by especially poorer strictions notalwaysfollowed, or off theage ofthemother, postpar- women;onlythewomenwho are better can afford multiparity,previous drink- tofollow tumhemorrhage werenotmentioned. Similarly, them strictly. on due whether to hot on inghotwaterand putting watercontainers the All of thelimitations mobility, forthecondi- fear shame, treatments werethesuggested of abdomen the reflect lackofautonomy ruor clearly werenot ralBangladeshi uterine massageand theuse ofoxytocics and implications tion; women haveimportant for mentioned. access to medicalservices-whether roufortheir of on are In contrast thefindings delivery thepla- tinecareor in case ofillness.The restrictions most to seem stringent centa, findings the aboutpostpartum hemorrhage at childbirth, thetimewhen and after during rather thanan inability womenmaymost care. to indicate lackofknowledge a needaccesstomedical
1995 1 26 Number January/February 27 Volume

Bleeding Discharge and of after childThe reported normal duration discharge seven days to two months, birth rangedwidelyfrom individual physiological difwhichmayhave reflected from their ferences becausethewomenwerespeaking The ownexperience. passageofbloodis considered beneficial thatitis believedto cleansethebirth in passage if and relieve cramps, especially clotsarepassed. of as Theparticipants no realconcept infection had Fever was frequently such,orofthecausesofinfection. but mentioned a symptom, invariably in conjuncas so Excess smellywhitedistionwithothersymptoms. was identified a comas knownas koshar dosh, charge, was childbirth. unpleasant The smell after monproblem and and attributed eating to garlic, fish, a mashofchilis, for to cuminwas considered be a good treatment it.In was to other cases,fouldischarge attributed evilspirits; insuchcases,a kobiraj called. was is abnormal discharge Becausewomenbelievethat or of due to supernatural influences theintake certain seektreatit that would actively foods, is unlikely they a consulting formally ment withantibiotics consider or As trained healthworker thiscondition. a result, for to adare postpartum infections unlikely be treated in equately this community.

and developedtetanus died. later discharge, aboutpostpartum As in thediscussion perinealtear knew thatan infected fewparticipants or withantibiotics that treated could be successfully suchinfections. or couldprevent treat cleansing perineal knewsomeof many theparticipants hand, On theother whichwerenotconsidfistulae, about obstetric thing with confused and eredtobe common weresometimes were That incontinence. theparticipants awareof stress thattheproblem-nowexfistulae indicates obstetric relatively in developedcountries-occurs rare tremely in community. frequently this
Prolapse

had that they seencases stated Someoftheparticipants where uterus the slipsdownwhena woman ofprolapse the Theysaid that prolapsed position. sitsina squatting with ulcerated bleedlookslikean egg,is sometimes part Some present. is on it,and discharge often ing points much about had said they notheard mothers that young becauseolderwomendo notspeakabout theproblem presentaa it.One womandescribed case withbreech unusualpressure overtheaba where TBAapplied tion a One TBA described domenand a prolapseoccurred. a jar womansheknewwhocarried heavywater during prolapse. in whichresulted a uterine herpuerperium, big the TheTBAtreated womanbyplacing arumleaves Tears Perineal withcloth for madea ring The on heruterus. TBA then All theparticipants thattearsare common thewomantositon. mentioned a childbirth. Although smalltearwas not duringfirst how to prevent prodescribed Some participants considered seriousproblem a becauseithealsbyitself, lapse.After in thechoti whena womanstays delivery, a larger was recognized problematic. SomeTBAs ghor, shouldhave herlegs closed together, as tear othershe with an- wise airwillgo insidetheopenedand raw uterus commercial stated they that cleanedsmalltears and Home rem- maycause prolapse.Ifheavyweight-lifting but tiseptic, others said theydid nothing. the during a edieswereused for For medium tears. example, piece puerperium avoided,prolapsecanbe prevented. The is of clothwithcuminseeds is made intoa ball,heated, womenin this the did study notmention use ofvaginal that andputonthetear. SomeTBAsmentioned thetears pessariesto control prolapse,thoughtheseare comwhichindi- monly heal gradually filling (granulation), up by availableinthetowns. Some catesthattheydid observethemafter delivery. stitches that tears require given Eclampsia Tetanus participants stated larger and werenotable to difatthehospital. the Not surprisingly, participants and the TBAs describedhow ferentiate and the Both the mothers between spasmscausedbytetanus the were thetwo"ways"(thevaginaand therectum) convulsions toeclampsia, these but conditions sometimes due as a tear known them wereidentified serious and become"one way,"whichindicates third-degree problems. to had recounted story Although the stitches. One mother of necessitating many thediscussants heardabouttetathat whohad suffered kindofa tearand had nus,no one spontaneously this mentioned it could be ofa friend of No to up. gone to thehospital have it stitched The friend prevented vaccination. sense was indicated by edemaand thedevelwas unabletohave anymorechildren. Two case histo- there between beinga connection had tearas a cause ofdeathweredescribed. opmentof eclampsia. Many of the participants riesofperineal but An oldermother these toldthegroupabouta friend whose known whohad died from conditions, women evilspirits. tear and were infected, smelled, attracted they perineal hadbecome the believed conditions causedby flies. Thisfriend becameverysickand laterdied. Anare Because theseserious conditions believed to another womanwithan other oldermother described by causes,attempts themedisupernatural havewholly infected perineal whobecamepale,edematous, tear and cal profession introduce are them to services prevent to
28 Studies Family in Planning

and to notlikely be well understood maybe perceived or as ineffective irrelevant.

Problems Breast and appearedtobe quitecommon, the Breast problems to had participants a wholerangeofremedies deal with for Some said thatthebestremedy pain,heavithem. engorgement)(breast and excessmilksecretion ness, the ashaor dudh bara-is to express calledshajor locally excess milkbeforeallowingthebaby to feed on the said thatthebabyshouldfeedas much Others breast. be the of should squeezed as itcan,andthen rest themilk from a poulticeis obtained out. Sometimes medicinal a and put on thebreast.Occasionally jute thekobiraj the from kobiraj tiedaround breast. the is obtained string a includedtaking hotbathor recommendations Other with mashedtoand cumin garlic hot eating ricemixed as gether a paste. describedhow breastabscesses The participants and becomevery painful producepus. To orfora) (gote with plant of an problem, herbal this remedy type breast deOtherremedies saltmaybe rubbedon thebreast. witha spice ground weretheuse ofdal(lentils) scribed made a breast, placing poultice and and roller puton the (traditional mud on theaffected area.Ifa fakir ofriver healer)is called in,he waves a broomoverthebreast to continue feed usually the andexpresses pus.Mothers breastuntilthepain and pus on thehealthy thebaby became her are gone,butone womantoldus that milk and herbabydid notlikeit.She was toldthat smelly if the the babywouldgetan upsetstomach itdrank milk, so shefeditcow'smilk. used forbreastproblems In general, remedies the conusually in That breastfeeding werepractical nature. of tinuesdespitetheexistence abscessesdemonstrates Discussion idenand that localcustoms maybe beneficial areworth is postof study that findings this One oftheimportant and tifying promoting. in common thiscommuill is partum health probably withbreast nity.Most illnessesare well recognized, Diarrhea Postnatal Chronic and infections, prolapse problems, perineal recognized problems, is diarrhea not a conventionally Although A described. wide rangeof of severalwomende- beingthemostcommonly complication the puerperium, but of, is that it peoplelinkto deliv- treatments availablelocally, knowledge say, scribed as a condition rural is of in to and disorder is often antibiotics thetreatment infection rare.An apIt ery. is considered be a serious for unmet, basic whichis currently need exists, 1984;Rea, parent to thought be caused by spirits(Blanchet, careto be made availableto village health had 1981).The group participants a lot to say about postpartum the chronic and, diarrhea) infact, word women. shutika (postnatal beof is finding theexistence a tenacious Another an without diarrhea. canconnote abdominal problem of of causation disease;many the in dry lief thesupernatural described types shutika, two of Theparticipants beliefs. these Although reflect remedies available of are and wet.Thesignsand symptoms dryshutika in- locally services, local did study notinvestigate government digestionwithabdominalpain, loud bowel sounds, this used and treatment by In diarrhea themodelofdisease causation and weakness, loss ofweight. wetshutika, medicalin nature. strictly is healthworkers typically these signsand symptoms. accompanies be of of lifting Knowledge thebeliefs localwomenmust incorincluding Many thingscan cause shutika, if providers the of on working the poratedin thetraining health-care leafy vegetables, eating heavyweights,
1995 29 Volume 26 Number 1 January/February

delivery. 40 sex or dheki, having within daysafter nathe reflects spiritual of The prevention shutika iron of the During period choti, rods of ture itscausation. and ghor, cow the outside choti corners at arestuck four in ofspecialsignificance Hinducommuis dung(which ghor. aroundthechoti is nities) distributed of a described number treatments The participants forshutika,which are normallyprescribedby the is One treatment forthewomanto tie herbal kobiraj. and to medicine thehip,use a specialamulet, avoideatspecialexinvolved treatments twodays.Other ingfor In a from tree. one or suchas swimming hanging ercise, in a new pot, putsjute the treatment, kobiraj elaborate it to setsfire it,and turns overontoa plate of water. the Whentheheat from pot sucks up thewater,the the shutikais healed. In anothertreatment, kobiraj to the from umbilicus each string a stretchesmeasuring sideis affected. which to sideoftheabdomen determine side massagestheaffected (theone where The kobiraj inthen outward withoil,stroking is thestring longer) withthearmon thesame side. ward;he also does so Thebowelsoundsfadegradually. and treatment The multiple symptomatology that indicate itis probshutika with associated modalities descriptive but entity, a general a single clinical ablynot of of term thesymptoms a wholevariety pathologies. for of and ofthe investigation meaning nature shutika Further because scant published data is probablyjustified, that existon thiscondition can be used to help health with whenconfronted respondappropriately workers thecomplaint.

health services nottobe irrelevant underutilized are and bylocalwomen. In commonwithotherauthors(Aminand Khan, 1989;Bhatia,1981;Mita et al., 1988),we believe that manyofthedelivery practices described herein poare harmful are likely contribute thedetentially and to to velopment postpartum of morbidity. However,some traditional practices seemedlikely be ofbenefit to and aretherefore be encouraged. following a listof to The is common practices have identified beingharmful we as orbeneficial: Harmful practices: (1) internal manipulations massage and (2) introduction oilsintothevagina of or abdominal bands (3) use offundal pressure tight labor during (4) pulling theumbilical on cord or in to (5) choking inducing vomiting themother expedite placental delivery (6) notusinguterine massageto prevent treat and postpartum hemorrhage. Useful practices: an (1) adopting upright position walking and duringlabor the for (2) adopting squatting position delivery with (3) noninterference themembranes from attendants (4) havingpsychological support andbeinginfamiliar surroundings of local customs that The identification beneficial in health education or couldbe reinforced community shouldcertainly in community health-worker training to of be given equal importance theidentificationharmof fulpractices. for Respect and reinforcementbenefithe cial local customs likely improve relationship is to and medical between localcommunities formal services. birth an imafter is thepractice seclusion of Clearly, in the custom these communities. portant Although length variesaccording relito ofstrict adherence seclusion to itis when gionand socioeconomic circumstances, a time all women are particularly vulnerableto illnessand for Part whenseeking careis especially difficult them. of is of theattraction locallyavailabletreatments that homesor to womento leave their theydo notrequire a see a healer, who is frequentlyman.The difficulties in homesafter womenencounter leavingtheir delivery the that of suggest anyprogram careduring puerperium weekor twoafshouldincludehomevisitsin thefirst ter delivery. Food restrictions feature prominently thepuerin perium wellas during as pregnancy. Theserestrictions
in Planning 30 Studies Family

(Rizvi, importance to thought be ofnutritional areoften involvefoodsthatare not theyoften 1976).However, meat, and in such available poorfamilies, as fish, usually on that be can restrictions theamount eggs. Similarly, eat for to allowed only oncea day, exampleeaten-being poorfamisince significance, many maynotbe ofgreat food lies eat a ricemeal onlyonce a day. Postpartum the enforced during period are restrictions onlystrictly in this ofseclusion; periodmaybe veryshort Muslim in and,particularly, poorhomes.The prohouseholds may involvea changein what is eaten in scriptions level of households only,wherethegeneral better-off in rebe nutrition might higher any case. In contrast, which havealsobeendescribed on intake, strictions fluid 1988), studies(Ghosh,1968;Lals and Adarsh, in other if The to couldbe detrimental lactation, enforced. data on foodavoidancesuggestthatemphasison thegenmesof eralharmfulnessfoodtaboosinhealth-education and thatsuch messages sages may notbe necessary, of to shouldbe confined practices provedrelevance. and theTBAs differed the mothers Interestingly, and theproper ideas ofdiseasecausation in little their thatthey It have the to practices follow: was apparent such similarity leads to Although same beliefsystem. to it good rapport, mayalso actas a hindrance theuse for ofTBAs as a force changein thecare of pregnant If believethat women. TBAsdo nottruly andparturient will they a changein customs be beneficial, willnotbe mothers. abletoconvince whatthey keentodescribe TheTBAswereinitially but relaxed and in had learned their training, oncethey we began to recounttheirexperiences, questioned their had From practices. whether training changed their we that with mothers, learned the many thediscussions are by deliveries notconducted TBAsat all,butbyrelatives.We believethatthewhole area ofTBA training healthrequiresfurther on reand its effect maternal deal ofgovernment as money search, especially a great in in Studies other counis beinginvested TBAtraining. of trieshave suggestedthatthe magnitude improveTBA training healththatarisefrom in ments maternal may be quite small (Greenwoodet al., 1990;Jordan, TBA trainfrom too 1989).Probably muchis expected is to ing;thechoicefacedby governments either abanand in indon their altogether to invest other training care or such centers, terventions, as obstetric in health and of the to revise radically objectives nature training to of the to reflect reality whatTBAs can be expected achieve. of the revealedthat concepts anteThe discussions and a natalcarefor normal pregnancy ofriskdetection medical is in thesensethattheterm used by Western Theparticipants were practitioners alientothewomen.

did notsee thepointofconsulting health personnel if they werefeeling well. On theother hand,theimporof tance prevention reflected thenumerous is in precautions pregnant women meant follow. are to Thatthe preventive aspectofmodern antenatal carehad notbeen incorporated thewomen'sbelief into system partly reflects lack of healtheducationand also revealsthe a highly medicalized nature pregnancy of services,model a that alientothe is belief of systems village women. Clearly,health workers must informed and sensitive be of to thebeliefs rural of womenifeffective communication is toexist.

health during and afterchildbirth.Clearly, improvementsin thehealthcare ofparturient women are badly needed. However, forprograms of deliveryand postpartumcare to improvematernalhealth,theymusttake into considerationnot only the cultural constraints on women at this time but also the existing beliefs and wealth ofknowledge of thewomen themselves.

Acknowledgments
Theauthors wouldliketothank following the peoplefor their helpwith study: this Nasreen Huq,Mahmooda Rahman Khan, Itu Rani,Fazlul Karim,and Sheuli Kabir,all withBRAC; Sushila and FauveauoftheInternational Zeitlyn Vincent Centre Diarrhoeal for DiseaseResearch, GraBangladesh; Wendy all ham, Patricia and the Vaughan, Oona Campbell, with London SchoolofHygiene and Tropical the Medicine; Overseas funded study; Administration which the Development (UK), and mostimportant, villagemothers traditional the and birth time participate the in attendants kindly to who gave oftheir discussions. focus-group

Conclusions
Thisstudydemonstrates valuableinsights be that can obtained usingrapidqualitative by to techniques invesand beliefs practices tigate abouthealth in problems the community. Themain that findings haveimplicationsfor policyare: (1) Postpartum morbidity likely be common is to in thiscommunity, theneed for but health careis notbeingmet. (2) The beliefsystem ruralwomenemphasizes of ill that health theresult supematural is of causes. (3) Training TBAsdoesnotsubstantially either alter their belief systems their or practices. (4) Somecommon traditional delivery practices are harmful health, others benpotentially to but are eficial. (5) Thepractice seclusion of servesas a major barrier health-care to seeking following delivery.

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