By Catherine Sanders – ISIS Research Associate
The Problem: Multiple Ways of Perceiving Motherhood and its Risks
In Uganda, many obstacles bar access to safe pregnancy and delivery in hospitals. Some of these obstacles are material, such as money for hospital costs and transport, and the condition of roads in rural areas. Others are the kinds of obstacles deemed “cultural”. As the Research Associate for ISIS, I recently spent seven weeks in Uganda where I began exploring community attitudes about pregnancy and delivery to help us understand why women choose (not) to deliver at the hospital (Dr. McKay, ISIS Director of Research, Monitoring and Evaluation gives a brief introduction in a previous post).
According to the anthropological literature, there are three preconditions that influence decisions about having children: sufficient motivation, opportunity, and the availability of rational (cost/benefit) choices. In our research in the Nakeseke district of Uganda, we observed that, contrary to popular belief, motivation was not one of the main impediments to hospital birthing. Opportunity and different methods of calculating risk were more important.
RELATIONS BETWEEN HOSPITALS AND COMMUNITIES
Many obstacles present themselves to Ugandan women when deciding where to deliver their children. Social factors, such as the way mothers are treated at hospitals or clinics (almost all the mothers talked of being treated harshly at hospitals for everything from wearing dirty clothes to not bringing their own supplies) played a larger-than-expected role in women’s decisions. When referring to the home-birthing context, the descriptions, “compassion”, “comfort”, and “care” contrasted sharply with the business of hospital birthing. Women repeatedly invoked the impersonal nature of hospital relations when describing their fears about hospital visits. Nurses, for their part, are often overworked, underpaid, and understaffed and unable to treat mothers with patience and care. So, women simply weren’t as eager to pay more money and risk the perils of rural Ugandan transport while pregnant (often on a motorcycle) for unsatisfactory interpersonal trade-offs.
In the US and other Western countries, the popularity of non-hospital alternatives in childbirth has encouraged biomedical institutions to modify childbirth conditions and forge partnerships with their alternative counterparts. These collaborations improve the quality of care that mothers get from their midwives as well as the comfort level and interpersonal interactions that occur in biomedical facilities.
BEING A GOOD MOTHER MEANS HOSPITAL DELIVERY
Women’s views about what defines a good woman in Uganda encourage hospital delivery. When talking with mothers, I found that in most cases, being a good woman necessarily involved motherhood, even the mere ability to bear children. This means that successfully bearing children in Uganda is not simply an evolutionary or family goal. It is also a symbolic act that reinforces social success for the Ugandan female. For most women I talked to, this emphasis on successful delivery led to the desire to have children in a hospital, because it was well-known that the hospital has facilities that may keep mothers and babies alive in the event of complications.
WHAT HOSPITALS CAN DO
In 2006, The ISIS Foundation supported a Traditional Birth Attendant (TBA) training programme that informed TBAs about safe practices, such as sterilisation of equipment and recognition of signs for referral to a hospital. However, in Uganda, religious stigmas and a staunch anti-TBA government position impeded the marriage of biomedical to traditional methods of giving birth, and ended training programmes like these because they were thought to lead to higher mortality.
However, Ugandan women’s voices clearly urge better social partnerships between hospitals and the communities they serve. At Kiwoko Hospital, we will be working on a variety of ways of enhancing the comfort, care, and compassion associated with hospital births. Stay tuned!