Josephine Masedi hears the cry from next door.
She stands up and walks briskly into her neighbour’s house to find the pregnant young woman gripping the arm of a couch.
Her sweaty face is contorted with pain; she is in labour.
Keeping her knees apart, she sinks to the floor, while Masedi grips her shoulders reassuringly, before rushing off to find a mat for the new mother to sit on.
Three years later, at a small village near Tzaneen, Limpopo, 58-year-old Masedi, who is a cleaner at the local hospital, recounts the tale: “My neighbour had earlier on called the clinic and they told her to come but it was too late and while in the toilet the baby’s head popped out.”
Masedi jumps off the white plastic chair on which she sits, kneels on the floor and demonstrates how she helped her neighbour to give birth to twins on the floor of her home.
“I have no training in midwifery but knew a bit from witnessing a few childbirths,” she says, her eyes flashing beneath her grey-speckled eyebrows. “And, of course, I’ve had four babies of my own.”
Although Masedi’s neighbour had no complications during this home delivery, according to a specialist gynaecologist at the University of Cape Town, Tham Matinde, delivering twins at home is especially risky.
“Twins are a complicated situation that should be handled very carefully by an experienced team. These pregnancies have increased complications and mothers can bleed to death after delivery,” he says.
But giving birth at home is nothing new to Masedi or her friends and family in Mogoboya village. In fact, it is one of the reasons why women in this area, and elsewhere in South Africa, miss out on antenatal and postnatal care services provided for free by the government.
South Africa lags behind the United Nation’s millennium development goal relating to maternal mortality. Health department figures show the country has 269 maternal deaths per 100 000 live births as opposed to the 2015 target of 38.
Maternal health has been made priority by the department.
Government figures show that only half of South African women attend antenatal appointments before 20 weeks into their pregnancy, despite the health department recommending a first visit before 14 weeks.
In a 2010 study in the journal Midwifery, the authors highlight the cultural practices that influence the way pregnant women access health services in Limpopo, recommending that “indigenous beliefs and practices … be incorporated into the midwifery curriculum, so that the health sector is able to meet the needs of all members of the community”.
Bhekisisa visited Mogoboya to find out where culture and healthcare meet for pregnant women in this village.
Traditional healer Flora Mmatsie gives pregnant women a special rope to protect them
Cultural secrecy to pregnancyPregnancy, says Masedi, especially in the early months, is a closely guarded secret in her village. The due date is never announced because it is thought to protect the baby from evil attacks by witches.
“You might find there is a person targeting you. If they know your due date they can make something happen when I give birth to the child – the baby or I can die,” she explains.
Mabel Makoala and Irene Mogoboya, community healthcare workers in the village, are concerned that some of the women might miss out on antenatal care, or go too late, because they want to keep their pregnancy a secret.
“When attending antenatal care the women are monitored and checked for health problems. After giving birth they are supposed to come for postnatal care during which they are taught about correct feeding practices and immunisations,” says Mogoboya.
Her colleague Makoala adds: “They do not even trust us to keep their secret and only present at the clinic at seven months, while others give birth at home because no one in the family knows their due date.”
This fear of being bewitched while pregnant is a strong belief in Mogoboya and many superstitions are attached to it.
Masedi says pregnant women are sometimes encouraged to drink their own urine to guard against poisoned food. “People believe the mother’s urine is clean and will flush out the poison.”
Matinde says that impurities from the women’s metabolism can be found in the urine, which may be harmful to the mother.
Flora Mmatsie, a traditional healer in the area, says she gives pregnant women a special rope to wear around their stomachs until they are eight months pregnant.
“Encased in the rope are bones of a certain animal known only as ‘phoku’, which is found in Kruger National Park. It protects the woman against miscarriage that might occur if jealous people target her,” she says.
Once the baby is delivered the traditional healer or an older female member of the family ties a rope containing a bone of the phoku around the baby’s neck for protection from witch attacks, according to Mmatsie, a 62-year-old grandmother of seven.
The 2010 report in Midwifery points out that “fear of bewitchment” was a major barrier and “influence on attendance at antenatal clinics”.
They also note that “women use herbs to preserve and protect their unborn infants from harm and trust the knowledge of traditional birth attendants, over the harsh treatment from midwives in hospitals and clinics”, who are perceived to look down on their indigenous beliefs and practices.
Howard Manyonga, from the University of the Witwatersrand’s Reproductive Health and HIV Institute, emphasises the importance of early, before 12 weeks, and continuous antenatal care, particularly to check for HIV and prevent the virus from being transmitted from HIV-positive mothers to the babies.
“Abnormalities like Down’s syndrome can also be picked up from early antenatal checks. This gives the mother options, either to terminate the pregnancy or carry it to full term but with full knowledge of what to expect,” he says.
Manyonga argues that, because many patients in rural areas consult traditional healers more than they do public health facilities, there is a need to enrol this category of health worker in educational activities about safe practices in maternal health.
Concern: Mable Makoala and Irene Mogoboya say women keep their pregnancy a secret
BreastfeedingThe health department introduced a policy of “exclusive breastfeeding” in 2011 to mitigate against child deaths as breast milk is nutritious with immunity-building properties, according to Manyonga.
“Breast milk contains all the nutrients that the baby needs in the right proportions and has special proteins called antibodies, absent in formula milk, that make the baby immune to common infections,” he says.
The department’s policy, in line with the World Health Organisation (WHO) and the UN Children’s Fund, recommends that mothers start to breastfeed within the first hour after birth and that they exclusively breastfeed their infants for the first six months of life (feeding the baby nothing but breast milk).
Research studies have shown that if other foods are introduced into the diet this early, such as solids or water, an HIV-positive mother increases the risk of transmitting the virus to the baby. If breastfed alone, however, that risk is greatly decreased, Manyonga says.
A 2010 WHO bulletin highlighted the battle that health workers faced with changing the attitudes and habits of HIV-infected mothers to prevent them from infecting their babies through breastfeeding.
In 2012, South Africa had one of the lowest exclusive breastfeeding rates in the world: only 8% of mothers exclusively breastfed their babies for six months, according to the charity organisation Save the Children.
Women in Mogoboya are a case in point: they say they’re aware of the country’s exclusive breastfeeding policy, but disagree with it and therefore don’t follow it.
Masedi explains that when babies cry a lot, they are given soft porridge at two or three weeks.
“You find that when you breastfeed, the milk is not enough and the baby will constantly cry but once you give them porridge they settle down,” she says.
Another villager, Rosina Shokane, says her 15-year-old son used to cry a lot as a baby.
“The moment I gave him cereal at three weeks, the house became quieter,” she says.
According to Masedi, new mothers in the village are urged to express the yellowish liquid known as colostrum, which precedes breast milk, to prevent the baby from drinking it, because they believe it is “dirty”.
Squeezing her right breast, she says: “It opens up the holes in the nipple and gets rid of all the dirt that might be trapped there and thereafter the milk will come out.”
But multiple research studies have shown that this liquid is highly beneficial to a newborn and one of the most nutritious substances a baby can be fed within the first few hours after birth.
“The first milk, colostrum, contains high concentrations of the good stuff that helps prevent early neonatal illnesses. We highly recommend it for newborns,” Matinde says.
Risk of infectionAlthough many women in the village attend the clinic if their babies are sick, people often trust traditional healers more, according to community healthcare workers Makoala and Mogoboya.
“For some illnesses, like a sunken fontanel, the traditional healer has the best treatment but for immunisations we go to the clinic,” Makoala says.
Both caregivers nod their heads in agreement.
When a baby’s fontanel is sunken, explains Mmatsie, who has been a traditional healer for more than 20 years, she makes incisions with a razor blade on it.
“A lowered fontanel means the child is sick and so I make four incisions on the head and then rub in herbs,” she says.
Manyonga explains that, according to medical research, a sunken fontanel is a sign that a baby is dehydrated either because of poor breastfeeding or excessive loss of fluid from diarrhoea.
“Children with depressed fontanels should be taken to a healthcare facility without delay to receive treatment. They can start the first aid at home with oral salt and sugar solution, which mothers can easily be taught how to prepare,” he says. “Dehydration is a major killer of South African newborns.”
“There is the additional risk that if the healer uses the same razor blade on many patients, they will transmit bloodborne diseases to the child. These include HIV and hepatitis, both of which are very common in South Africa,” Manyonga says.
During a health briefing on child mortality in Parliament last year, Health Minister Aaron Motsoaledi said the number of deaths of children under five in South Africa remained high at 47 per 1 000, and yet most of these were preventable. He singled out diarrhoea as one of the biggest preventable causes of death for babies.
Both caregivers warn against another tradition performed on the baby after birth: cow or chicken dung is smeared on the newly cut navel to make it heal faster.
“We advise them against this but it is not easy because it has been practised for years,” says Makoale.
Manyonga says that each year “we lose many children to various infections and when parents use chicken or cow dung on the navels they are exposing their children to the risk of infection by bugs found in soil and animal waste. So services like postnatal care present yet another opportunity to stem risks of infection that are common soon after birth.”
Matinde says the umbilical cord should be kept free from infection and cleaned with a sterile alcohol swab and “it will dry and fall away on its own”.
Masedi warns that people in Mogoboya believe that once the umbilical cord is cut it must be given to the mother to dispose of in private.
“You must not let that flesh get into the hands of anyone else. The sisters even give it back to you at the clinic because people can use that bit of flesh against you,” she says, pointing her finger accusingly at nobody in particular.
Trust in her cultureStraightening her skirt and shifting her slight frame in the white plastic chair, Masedi gazes out of the window, her eyes sweeping across the banana trees in the yard outside.
It is an especially humid evening with a low cloud of fog dulling the orange sunset behind the trees.
“All this talk of pregnancy reminds me of having my lastborn 18 years ago,” she says, her eyes widening as she remembers.
“I woke up with what I assumed at the time to be hunger pangs but when I sat up I realised that my water had already broken. The hunger pangs were in fact labour pains.”
Although she had given birth to her other three children at home, she had decided that her fourth child would be delivered in hospital.
“When I got a job as a cleaner at the hospital I began to appreciate giving birth safely at a health facility,” she says.
However, as fate would have it, her son arrived early.
“When I realised that I was about to have my baby I screamed for my mother, who was in the next room, to come,” she says.
They had no time to prepare and right there on the floor of her bedroom she squatted and gave birth to her last-born with the assistance of her mother, who used a razor blade to snip the umbilical cord. Her son wrote matric this year.
Although Masedi believes that medical care is a safer option, she trusts her culture more.
Masedi places her hands in her lap, an amused expression creeping over her face.
“It’s better anyway,” she laughs. “I can’t push a baby out lying down on a bed – it’s much easier to squat.”
Phyllis Mbanje was a Bhekisisa fellow from August to October 2014
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