The following section displays results under the topic of Maternal help and support. The key themes emerging from analysis were a) Spousal support and antenatal attendance, b) Professional support and family contribution around delivery, c) Postnatal care and challenges related to gender roles. The importance of antenatal care and expectations to fathers were given much attention both from mothers and traditional birth attendants, although not being a key focus of the topic guide. Support in delivery situations were found challenging for birth attendants, especially in cases of birth complications. Many women in the study were discontent with spousal and family contributions related to help and support in maternal issues, often related to pecuniary difficulties. Breastfeeding support and -information were found to be unsatisfactory, and gender inequity put a strain on women’s decision-making and autonomy regarding reproductive health issues. Postnatal care was found close to non-existent, except for the 6-weeks check-up combined with the vaccination program. Observations by the researcher could occasionally deviate from the view of the participants and is conveyed explicitly.
Spousal support and antenatal attendance
Mothers’perspective
Matters concerning breastfeeding and post-partum care are recommended topics during antenatal classes. Among the interviewed mothers, knowledge of the importance of antenatal care was widespread, although many admitted non-attendance at antenatal classes for various reasons like road conditions, distance, and transport cost:
“Sometimes a woman can request some money for transport from the husband and he tends to refuse to give out the money to the wife hence ending up not going for antenatal care. That’s why the husbands send their wives to go to these TBAs because for them they will not pay money”. (Mother 35-45 years, village 4)
From the TBA’s perspective
Antenatal care was an important issue also for the traditional birth attendants interviewed, and they stressed the significance of attending antenatal classes as a way to gain information on hygiene and general baby care, referring to some mothers as “totally green about some issues”. (TBA, village 7)
Some of the TBA’s confirmed the statements of the mothers, that non-attendance in antenatal classes was a reflection of the total financial situation in the family, where the lack of funds prohibited transportation to facilities:
“ What makes ladies not to go for antenatal care is that the husband might not provide transport to the pregnant mother that will make her lose moral of going to the hospital because of her husband’s poverty”. (TBA 50-80 years, village 7)
Professional support and family contribution around delivery
Mothers’ perspective
Sometimes reaching professional help was not possible and one mother explained in detail how she admired her husband for taking responsibility in asking a neighbour for assistance with delivering their baby due to rapid labour and difficulties obtaining transport. Reliance on and support from family members in times of need and during vulnerable circumstances can contribute to better coping. A young mother had positive experiences from helping other family members around the time of childbirth:
“I just learnt how to breastfeed from my elder sister because she raised all her children when I was the one taking care of her, so I got to learn it”. (Mother 15-25 years, village 6).
Nevertheless, many women showed resentment and anger towards negligent husbands and fathers regarding unmet expectations of help and support as well as on economic issues:
“A very big number of women from this village give birth from their homes just because they lack money and even the husbands do not fulfil their responsibilities, which sometimes leads to both infant and maternal mortality”. (Mother 35-45 years, village 4)
Contradictory to the expression of despair from the mother above, the researcher also witnessed many caring and supportive partners and husbands while present for observations at the Hospital and Health Centre. Fathers accompanying their partners could be seen anxiously waiting for hours outside the maternity ward, awaiting the birth of their baby son or daughter or travel long distances to reach the delivery.
Sometimes help and support for the mothers were provided through relations and acquaintances other than one’s family or professional health workers. Examples of this were the fellowship with other mothers, neighbours with children or village health team workers and traditional birth attendants.
Health workers’ perspective
On several occasions the researcher witnessed very young mothers coming together with their mothers-in-law for delivering at both the hospital and clinic. Being at a health centre with marginal resources and equipment when complications occurred, was described as a huge challenge for the health workers, and they often found themselves alone on duty. When there was need for referrals, it was the family’s responsibility to arrange for transport, but that was often described as difficult and unreliable. One midwife interviewed had a traumatic experience freshly in mind of how she struggled with finding transport for referral of a mother facing complications during labour, implicitly also describing her own support to the mother and her family:
“I was alone, and the baby was at the outlet, I was seeing the head actually. I tried several bodaboda names (scooter driver’s names), but their phones were off…before reaching (village 1) we got in an accident around the house near N. Then we reached the road, it was raining, totally raining, and the petrol got finished. And she was fitting (having seizures) with heavy rain. We stayed in (village 1) up to morning. They had to give magnesium, but it took long for her to give birth. She delivered when she was still fitting. They did episiotomy when she was still fitting”. (Midwife 19-35 years)
Postnatal care and challenges related to gender roles.
Mothers’ perspective
On the issue of nutrition and breastfeeding support, underlying feelings of being neglected and betrayed became transparent as shown in this quotation from a focus group discussion:
“Me, sometimes after giving birth I feel like eating posho (local dish from maize), but my husband tends to run away from his responsibilities and goes and marries other women, me I even fetch water for myself”. (Mother, 25-35 years, village 4)
Observations done by the researcher revealed supportive husbands or other family members during times of delivery on several occasions. Often it could also be a brother or sister of the mother who would assist her with caring for the newborn or fetching food and water for washing, however, the negative experiences were influencing the interview data.
Some mothers described how they received support from health workers when facing complications with breastfeeding:
“When I start breast feeding I get wounds on my breasts, then I start feeling some small stones. When I go to the hospital they have to first squeeze the breast for those small stones to move out, then I start breast feeding”. (Mother 25-35 years, village 4)
Recurrent topics raised by women attending focus group discussions were sexual activity after birth and family planning, where the discordance between the various needs of men and women were again proclaimed, and as the following quote shows, it could prove a risky affair for the women:
“If a woman goes for family planning on her own and the man gets to know it, it will just become a fight or even he can kill the wife. That’s why we want you and your management to organize and talk to them one day”. (Mother 35-45 years, village 4)
From observations in the hospital the researcher witnessed a young mother who had requested for tubal legation after having had four Caesarean sections. The procedure had been recommended and approved by the doctors for the health of the mother and her husband had signed the consent papers. On the day of the procedure the husband withdrew his approval and the mother was not allowed to go through with the surgery.
Unstructured dialogue with mothers during observations revealed that many were aware of other contraceptives like intra-uterus devices (IUDs), but intimidating stories of painful insertions and side-effects of infertility prohibited usage.
Health workers’ perspective
One midwife explained how she rarely had enough time to provide sufficient information and support involving breastfeeding. Often the midwives were alone on duty, and due to hectic work environments and sometimes attending to several mothers in labour at the same time, the information and support for breastfeeding were thus neglected:
“…most of the times I deliver them at night, then in the morning when you’re alone, you’re moving up and down, you’re this side and the other side, so I get less time (snapping fingers). And that one (time) I cannot deceive”. (Midwife 19-35 years)
Pre-scheduled or planned postnatal follow-up before vaccination at 6 weeks was not common or recognized among the health workers. When inquiring from the health workers about supporting mothers with breastfeeding or newborn issues, the general answer was that they told the mothers to return to the facility if they should face any challenges, but they also confirmed that this seldom occurred:
“Here we don’t know whether their villages have health workers there, we don’t know, but we tell her (the mother) when she gets any complaint to come back here”. (Midwife student 19-22 years)
Newborn vaccinations against Polio and BCG are normally given at the hospital and health centre before discharge. For women giving birth at home, the traditional birth attendant could offer advice to go to the hospital for vaccinations and measurements, but it was the mothers’ responsibility to follow up.
TBAs’ perspective
Making sure that the mothers initiated breastfeeding early were important to the TBAs, and when mothers faced challenges of sore nipples they would sometimes go to extreme measures to make the mothers start breastfeeding:
“There are some mothers when you tell her to breast feed the baby, she can hesitate that she feels nipple pain, me I even slap some of them for hesitating”. (TBA 50-80 years, village 1)
Some of the TBA’s interviewed took extra measures to follow up on the mothers they had helped with deliveries:
“Yes, I do visit them after some time from the day I discharged them to find out how they are doing, if they are in good condition both the mother and the baby”. (TBA 50-80 years, village 1)
Others explained how they recommended them to seek postnatal care and go for vaccinations at various health facilities.